Provider Demographics
NPI:1134272693
Name:BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC
Entity type:Organization
Organization Name:BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-285-6235
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-1039
Mailing Address - Country:US
Mailing Address - Phone:662-285-6235
Mailing Address - Fax:662-285-2516
Practice Address - Street 1:311 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-9795
Practice Address - Country:US
Practice Address - Phone:662-285-6235
Practice Address - Fax:662-285-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02032374Medicaid
MS02032374Medicaid