Provider Demographics
NPI:1659803948
Name:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC RESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:SHARDAE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-223-1634
Mailing Address - Street 1:9057 FIRETOWER RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-9411
Mailing Address - Country:US
Mailing Address - Phone:228-223-1634
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5200
Practice Address - Fax:601-984-2086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty