Provider Demographics
NPI:1790711273
Name:MISSISSIPPI METHODIST HOSPITAL & REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:MISSISSIPPI METHODIST HOSPITAL & REHABILITATION CENTER, INC.
Other - Org Name:METHODIST REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-364-3365
Mailing Address - Street 1:1350 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5112
Mailing Address - Country:US
Mailing Address - Phone:601-981-2611
Mailing Address - Fax:601-364-5369
Practice Address - Street 1:1350 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5112
Practice Address - Country:US
Practice Address - Phone:601-981-2611
Practice Address - Fax:601-364-5369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS43-278208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08420277Medicaid
MS08420277Medicaid