Provider Demographics
NPI:1659348076
Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity Type:Organization
Organization Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Other - Org Name:BROOKLYN FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEROLDEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DYSE
Authorized Official - Suffix:
Authorized Official - Credentials:
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:601-450-0231
Practice Address - Street 1:44 BROOKLYN JANICE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MS
Practice Address - Zip Code:39425-9731
Practice Address - Country:US
Practice Address - Phone:601-582-1188
Practice Address - Fax:601-582-8844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-03
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02142OtherCAHABA MEDICARE GR NUMBER
MS1821127OtherMS UNITED HEALTH CARE
MS09014664Medicaid
MS251864Medicare ID - Type UnspecifiedMS MEDICARE NUMBER