Provider Demographics
NPI:1578011417
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 GRENDA SPECIALTY PEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO GRENADA/HOLMES COUNTY
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-227-7172
Mailing Address - Street 1:965 AVENT DR STE 100B
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5045
Mailing Address - Country:US
Mailing Address - Phone:662-227-7172
Mailing Address - Fax:
Practice Address - Street 1:965 AVENT DR STE 100B
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No282NR1301XHospitalsGeneral Acute Care HospitalRural