Provider Demographics
NPI:1629394853
Name:EAST MISSISSIPPI STATE HOSPITAL
Entity Type:Organization
Organization Name:EAST MISSISSIPPI STATE HOSPITAL
Other - Org Name:JAMES T. CHAMPION NURSING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-581-7878
Mailing Address - Street 1:PO BOX 4128
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-7600
Mailing Address - Fax:601-581-7676
Practice Address - Street 1:4555 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5429
Practice Address - Country:US
Practice Address - Phone:601-581-7600
Practice Address - Fax:601-581-7676
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MISSISSIPPI STATE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-13
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1034313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01831556Medicaid