Basic Information
| Provider Information | |||||||||
| NPI: | 1154317527 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 CLINTON CENTER DRIVE | ||||||||
| Address2: | CBO - SUITE 4300 | ||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
| FaxNumber: | 6018156301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668427574 | ||||||||
| FaxNumber: | 6018156301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRIMSLEY | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 6018158732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 341600000X | N | Transportation Services | Ambulance | 282N00000X | 11-199 | MS | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 18204400002 | 05 | PA | MEDICAID | 250001 | 05 | TN | MEDICAID | HS022OP | 05 | AK | MEDICAID | 372079 | 05 | AZ | MEDICAID | HS022IP | 05 | AK | MEDICAID | XHSP32759 | 05 | CA | MEDICAID | XHSP42759 | 05 | CA | MEDICAID | 009908195 | 05 | AK | MEDICAID | 108481105 | 05 | AR | MEDICAID | 1691529 | 05 | NY | MEDICAID | 200125970A | 05 | IN | MEDICAID | 23487232 | 05 | CO | MEDICAID | ========= | 01 | MS | AETNA | OTHER | 000020149 | 01 | MS | BLUE CROSS OF MS | OTHER | 00550462 | 05 | MS | MEDICAID | 1430321 | 05 | KY | MEDICAID | ========= | 05 | IL | MEDICAID | 00020149 | 05 | MS | MEDICAID | 05375086 | 05 | MS | MEDICAID | 1000022942 | 05 | DE | MEDICAID | 100510031 | 05 | NV | MEDICAID | 1185270 | 05 | NV | MEDICAID | 00075205 | 05 | MS | MEDICAID | 2314400 | 05 | ID | MEDICAID | 908079 | 05 | IA | MEDICAID | ========= | 01 | MS | COMMERICAL | OTHER | ========= | 01 | MS | BENMARK | OTHER | 10672004 | 05 | MO | MEDICAID | 1154317527 | 05 | MI | MEDICAID | 1731200 | 05 | LA | MEDICAID | 2500001 | 05 | NC | MEDICAID | 000020149 | 01 | MS | STATE OF MS | OTHER | 0104140 | 05 | DC | MEDICAID | 188845 | 05 | OH | MEDICAID | ========= | 01 | MS | TRICARE | OTHER | HOS1149N | 05 | AL | MEDICAID |