Provider Demographics
NPI:1225342173
Name:EAST MISSISSIPPI STATE HOSPITAL
Entity Type:Organization
Organization Name:EAST MISSISSIPPI STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:MPPA
Authorized Official - Phone:601-581-7878
Mailing Address - Street 1:P.O. BOX 4128
Mailing Address - Street 2:WEST STATION
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-7600
Mailing Address - Fax:601-581-7676
Practice Address - Street 1:4555 HIGHLAND PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307
Practice Address - Country:US
Practice Address - Phone:601-581-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS31-136283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital