Provider Demographics
NPI:1699857433
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:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE ADMINISTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-986-4699
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-2342
Mailing Address - Fax:601-984-4657
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:PFS
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-4619
Practice Address - Fax:601-984-4657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCH5738OtherRR MEDICARE
MS09015456Medicaid
MS=========NOtherBLUE CROSS BLUE SHIELD
MSCH5738OtherRR MEDICARE
MS09015456Medicaid
MS09015456Medicaid