Provider Demographics
NPI:1932538527
Name:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity Type:Organization
Organization Name:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Other - Org Name:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER-GRENADA SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-984-4113
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-4113
Mailing Address - Fax:
Practice Address - Street 1:965 AVENT DR
Practice Address - Street 2:SUITE 100A
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7444
Practice Address - Fax:662-227-7443
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-05
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS326164Medicare PIN