Basic Information
Provider Information | |||||||||
NPI: | 1275566515 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIONEER HEALTH SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1100 | ||||||||
Address2: |   | ||||||||
City: | MAGEE | ||||||||
State: | MS | ||||||||
PostalCode: | 391111100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018496440 | ||||||||
FaxNumber: | 6018497557 | ||||||||
Practice Location | |||||||||
Address1: | 301 8TH AVE SW | ||||||||
Address2: |   | ||||||||
City: | MAGEE | ||||||||
State: | MS | ||||||||
PostalCode: | 391113967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018496440 | ||||||||
FaxNumber: | 6018497557 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 06/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCNULTY | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6018494112 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: | CRT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | MS |   | MEDICAID |