Provider Demographics
NPI:1528595667
Name:STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity Type:Organization
Organization Name:STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Other - Org Name:UMMC GRENADA SPECIALTY CLINIC- WINONA FAMILY MEDICAL CLINIC RHC
Other - Org Type:Other Name
Authorized Official - Title/Position:ASST. CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-815-9818
Mailing Address - Street 1:418B N APPLEGATE ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1827
Mailing Address - Country:US
Mailing Address - Phone:662-283-4433
Mailing Address - Fax:
Practice Address - Street 1:418B N APPLEGATE ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1827
Practice Address - Country:US
Practice Address - Phone:662-283-4433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health