Provider Demographics
NPI:1407886146
Name:MISSISSIPPI HOSPITAL FOR RESTORATIVE CARE, INC.
Entity Type:Organization
Organization Name:MISSISSIPPI HOSPITAL FOR RESTORATIVE CARE, INC.
Other - Org Name:RESTORATIVE CARE HOSPITAL AT BAPTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/CORPORATE CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-968-5130
Mailing Address - Street 1:PO BOX 23090
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3090
Mailing Address - Country:US
Mailing Address - Phone:601-968-1362
Mailing Address - Fax:601-292-4592
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-968-5130
Practice Address - Fax:601-968-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23-319282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00220174Medicaid
MS25-2003Medicare ID - Type Unspecified