Provider Demographics
NPI:1548358153
Name:MISSISSIPPI BAND OF CHOCTAW INDIANS
Entity type:Organization
Organization Name:MISSISSIPPI BAND OF CHOCTAW INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHIEF
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-656-2211
Mailing Address - Street 1:210 HOSPITAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:MS
Mailing Address - Zip Code:39350-6781
Mailing Address - Country:US
Mailing Address - Phone:601-656-2211
Mailing Address - Fax:601-663-7721
Practice Address - Street 1:210 HOSPITAL CIRCLE
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6781
Practice Address - Country:US
Practice Address - Phone:601-656-2211
Practice Address - Fax:601-663-7721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI BAND OF CHOCTAW INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS025341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00050014Medicaid
MS=========BOtherMSCHIP
MS00050014Medicaid
MS=========BOtherBLUE CROSS BLUE SHIELD