Provider Demographics
NPI:1497202527
Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity Type:Organization
Organization Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Other - Org Name:COLLINS ELEMENTARY SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:601-545-8700
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:401 DOGWOOD STREET
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-0000
Practice Address - Country:US
Practice Address - Phone:601-765-4383
Practice Address - Fax:601-450-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
251048OtherMS MEDICARE PTAN
MS09405885Medicaid