1194738393 NPI number — STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

Table of content: (NPI 1194738393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194738393 NPI number — STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HOLMES FAMILY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194738393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 N STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-834-1321
Provider Business Mailing Address Fax Number:
601-815-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18295 EMORY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39192-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-834-1321
Provider Business Practice Location Address Fax Number:
601-815-6301
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMSLEY
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
601-815-8732

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09016279 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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