Provider Demographics
NPI:1922384551
Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:LUCIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-576-7853
Mailing Address - Street 1:PO BOX 1700
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39215-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8705 NORTHWEST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2430
Practice Address - Country:US
Practice Address - Phone:662-393-2775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020500Medicaid