Provider Demographics
NPI:1407114432
Name:EMMANUEL HEALTH SERVICES
Entity Type:Organization
Organization Name:EMMANUEL HEALTH SERVICES
Other - Org Name:EMMANUEL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-209-5133
Mailing Address - Street 1:PO BOX 2056
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158-2056
Mailing Address - Country:US
Mailing Address - Phone:601-605-8820
Mailing Address - Fax:601-605-8920
Practice Address - Street 1:637 HIGHWAY 51 NORTH
Practice Address - Street 2:SUITE E
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-209-5133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR845316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty