Basic Information
| Provider Information | |||||||||
| NPI: | 1619025269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST MS HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BYHALIA FAMILY HEALTH CENTER - DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 EAST BRUNSWICK AVE. | ||||||||
| Address2: | P.O. BOX 698 | ||||||||
| City: | BYHALIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628382163 | ||||||||
| FaxNumber: | 6628387944 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 EAST BRUNSWICK | ||||||||
| Address2: | |||||||||
| City: | BYHALIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628382163 | ||||||||
| FaxNumber: | 6628387944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCKINNEY | ||||||||
| AuthorizedOfficialFirstName: | MARJORIE | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6628382163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 9011641 | 05 | MS | MEDICAID |