Provider Demographics
NPI:1447396833
Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-906-0879
Mailing Address - Street 1:570 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:601-906-0879
Mailing Address - Fax:
Practice Address - Street 1:570 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-906-0879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019240Medicaid