Provider Demographics
NPI:1083658595
Name:PIONEER HEALTH SERVICES OF MONROE COUNTY, INC
Entity Type:Organization
Organization Name:PIONEER HEALTH SERVICES OF MONROE COUNTY, INC
Other - Org Name:CHESTNUT MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:CRT
Authorized Official - Phone:691-849-4112
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-1100
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-849-7557
Practice Address - Street 1:500 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-3337
Practice Address - Country:US
Practice Address - Phone:601-369-9525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015888Medicaid
MS09015888Medicaid