STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

Provider Demographics

• NPI: 1154317527
• Name: STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
• Entity Type: Organization
• Organization Name: STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
• Authorized Official - Title/Position: INTERIM CFO
• Authorized Official - First Name: JEFFREY
• Authorized Official - Last Name: GRIMSLEY
• Authorized Official - Phone: 601-815-8732
• Mailing Address - Street 1: 504 CLINTON CENTER DRIVE
• Mailing Address - Street 2: CBO - SUITE 4300
• Mailing Address - City: CLINTON
• Mailing Address - State: MS
• Mailing Address - Zip Code: 39056
• Mailing Address - Country: US
• Mailing Address - Phone: 601-984-1000
• Mailing Address - Fax: 601-815-6301
• Practice Address - Street 1: 2500 N STATE ST
• Practice Address - City: JACKSON
• Practice Address - State: MS
• Practice Address - Zip Code: 39216
• Practice Address - Country: US
• Practice Address - Phone: 866-842-7574
• Practice Address - Fax: 601-815-6301
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-09-21
• Last Update Date: 2021-12-14

Provider Licenses

State	License ID	Taxonomies
		282N00000X, 341600000X
MS	11-199	282N00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	282N00000X	Hospitals	General Acute Care Hospital
No	341600000X	Transportation Services	Ambulance

Provider Identifiers

State	Identifier ID	ID Type	Issuer
PA	18204400002	Medicaid
TN	250001	Medicaid
AK	HS022OP	Medicaid
AZ	372079	Medicaid
AK	HS022IP	Medicaid
CA	XHSP32759	Medicaid
CA	XHSP42759	Medicaid
AK	009908195	Medicaid
AR	108481105	Medicaid
NY	1691529	Medicaid
IN	200125970A	Medicaid
CO	23487232	Medicaid
MS	=========	Other	AETNA
MS	000020149	Other	BLUE CROSS OF MS
MS	00550462	Medicaid
KY	1430321	Medicaid
IL	=========	Medicaid
MS	00020149	Medicaid
MS	05375086	Medicaid
DE	1000022942	Medicaid
NV	100510031	Medicaid
NV	1185270	Medicaid
MS	00075205	Medicaid
ID	2314400	Medicaid
IA	908079	Medicaid
MS	=========	Other	COMMERICAL
MS	=========	Other	BENMARK
MO	10672004	Medicaid
MI	1154317527	Medicaid
LA	1731200	Medicaid
NC	2500001	Medicaid
MS	000020149	Other	STATE OF MS
DC	0104140	Medicaid
OH	188845	Medicaid
MS	=========	Other	TRICARE
AL	HOS1149N	Medicaid
ID	2314400	Medicaid
AL	HOS1149N	Medicaid