Provider Demographics
NPI:1013990530
Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Other - Org Name:TOMBIGBEE HOME HEALTH AGENCY 4B
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STATE HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:601-576-7634
Mailing Address - Street 1:797 S JACKSON ST
Mailing Address - Street 2:ROUTE 1 BOX 1049
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-7662
Mailing Address - Country:US
Mailing Address - Phone:662-456-3791
Mailing Address - Fax:662-456-3979
Practice Address - Street 1:797 S JACKSON ST
Practice Address - Street 2:ROUTE 1 BOX 1049
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-7662
Practice Address - Country:US
Practice Address - Phone:662-456-3791
Practice Address - Fax:662-456-3979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1381251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00070500Medicaid
MS00070500Medicaid