Provider Demographics
NPI:1841370749
Name:MS STATE DEPT OF HELTH
Entity type:Organization
Organization Name:MS STATE DEPT OF HELTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLAMS ADJUSTER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-576-7566
Mailing Address - Street 1:769 CRANE RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-6110
Mailing Address - Country:US
Mailing Address - Phone:601-267-5027
Mailing Address - Fax:
Practice Address - Street 1:3128 8TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4753
Practice Address - Country:US
Practice Address - Phone:601-482-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR505307363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124030Medicaid
MSQ06099Medicare UPIN