Provider Demographics
NPI:1225012255
Name:MISSISSIPPI STATE UNIVERSITY
Entity Type:Organization
Organization Name:MISSISSIPPI STATE UNIVERSITY
Other - Org Name:JOHN C LONGEST STUDENT HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-325-5895
Mailing Address - Street 1:PO BOX 6338
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762-6338
Mailing Address - Country:US
Mailing Address - Phone:662-325-2431
Mailing Address - Fax:662-325-8888
Practice Address - Street 1:360 HARDY RD
Practice Address - Street 2:
Practice Address - City:MISSISSIPPI STATE
Practice Address - State:MS
Practice Address - Zip Code:39762
Practice Address - Country:US
Practice Address - Phone:662-325-2431
Practice Address - Fax:662-325-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012379Medicaid