Provider Demographics
NPI:1972689313
Name:EAST MISSISSIPPI STATE HOSPITAL
Entity Type:Organization
Organization Name:EAST MISSISSIPPI STATE HOSPITAL
Other - Org Name:REGINALD P WHITE NURSING FACILITY
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS SERVICES DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HAMRICK
Authorized Official - Last Name:ENTREKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-581-7969
Mailing Address - Street 1:P.O. BOX 4128
Mailing Address - Street 2:WEST STATION
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-7562
Mailing Address - Fax:601-581-7676
Practice Address - Street 1:4555 HIGHLAND PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-2903
Practice Address - Country:US
Practice Address - Phone:601-581-7562
Practice Address - Fax:601-581-7676
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MISSISSIPPI STATE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
MS1230313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00023122Medicaid
MSC00020Medicare ID - Type UnspecifiedGROUP NUMBER