Provider Demographics
NPI:1730753914
Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC
Entity type:Organization
Organization Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEROLDEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DYSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-545-8700
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-450-0231
Practice Address - Street 1:1760 OLD HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8235
Practice Address - Country:US
Practice Address - Phone:601-264-6724
Practice Address - Fax:601-796-9437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2022-11-04
Deactivation Date:2021-07-20
Deactivation Code:
Reactivation Date:2022-11-04
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)