Basic Information
| Provider Information | |||||||||
| NPI: | 1821738071 | ||||||||
| EntityType: | 2 | ||||||||
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| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
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| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018152005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2022 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRIMSLEY | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6018158732 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.