Provider Demographics
NPI:1033426820
Name:SAINT JUDE HOSPICE-MISSISSIPPI,LLC
Entity Type:Organization
Organization Name:SAINT JUDE HOSPICE-MISSISSIPPI,LLC
Other - Org Name:SAINT JUDE HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEGENER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:515-221-9155
Mailing Address - Street 1:3166 W JACKSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-7154
Mailing Address - Country:US
Mailing Address - Phone:662-841-5907
Mailing Address - Fax:662-841-5910
Practice Address - Street 1:3166 W JACKSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-7154
Practice Address - Country:US
Practice Address - Phone:662-841-5907
Practice Address - Fax:662-841-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS094251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251589Medicare Oscar/Certification