Basic Information
Provider Information | |||||||||
NPI: | 1033426820 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINT JUDE HOSPICE-MISSISSIPPI,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAINT JUDE HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3166 W JACKSON ST | ||||||||
Address2: | SUITE 2 | ||||||||
City: | TUPELO | ||||||||
State: | MS | ||||||||
PostalCode: | 388017154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6628415907 | ||||||||
FaxNumber: | 6628415910 | ||||||||
Practice Location | |||||||||
Address1: | 3166 W JACKSON ST | ||||||||
Address2: | SUITE 2 | ||||||||
City: | TUPELO | ||||||||
State: | MS | ||||||||
PostalCode: | 388017154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6628415907 | ||||||||
FaxNumber: | 6628415910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2010 | ||||||||
LastUpdateDate: | 03/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEGENER | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5152219155 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 094 | MS | Y |   | Agencies | Hospice Care, Community Based |   |
No ID Information.