Provider Demographics
NPI:1386689438
Name:PIONEER HEALTH SERVICES OF MONROE COUNTY, INC.
Entity Type:Organization
Organization Name:PIONEER HEALTH SERVICES OF MONROE COUNTY, INC.
Other - Org Name:PIONEER FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
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:
Authorized Official - Phone:601-849-6440
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:601-849-1682
Mailing Address - Fax:601-849-1969
Practice Address - Street 1:502 JACKSON STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-0000
Practice Address - Country:US
Practice Address - Phone:662-369-9500
Practice Address - Fax:662-304-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08558036Medicaid
MS258515Medicare UPIN
MS08558036Medicaid