Provider Demographics
NPI:1336224179
Name:MISSISSIPPI STATE HOSPITAL AT WHITFIELD
Entity Type:Organization
Organization Name:MISSISSIPPI STATE HOSPITAL AT WHITFIELD
Other - Org Name:MISSISSIPPI STATE HOSPITAL COMMUNITY SERVICES MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-351-8000
Mailing Address - Street 1:P.O. BOX 1 - FISCAL SERVICES
Mailing Address - Street 2:3550 HIGHWAY 468 WEST
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8301
Practice Address - Street 1:350 CAPERS AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI STATE HOSPITAL AT WHITFIELD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X
MSDCS-MSH320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04972797Medicaid
MSC00171Medicare Oscar/Certification