Provider Demographics
NPI:1003226903
Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Other - Org Name:SOUTHAVEN HEALTH DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:STATE HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:601-576-7634
Mailing Address - Street 1:570 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:601-576-7635
Mailing Address - Fax:
Practice Address - Street 1:8705 NORTHWEST DR
Practice Address - Street 2:BUILDING A, SUITE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2430
Practice Address - Country:US
Practice Address - Phone:662-393-2775
Practice Address - Fax:662-393-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare