Provider Demographics
NPI:1700108578
Name:AMITE COUNTY MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:AMITE COUNTY MEDICAL SERVICES, INC.
Other - Org Name:GLOSTER DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-657-4326
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:GLOSTER
Mailing Address - State:MS
Mailing Address - Zip Code:39638-0427
Mailing Address - Country:US
Mailing Address - Phone:601-225-4119
Mailing Address - Fax:601-225-4620
Practice Address - Street 1:253 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:MS
Practice Address - Zip Code:39638
Practice Address - Country:US
Practice Address - Phone:601-225-4119
Practice Address - Fax:601-225-4620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013203Medicaid