Provider Demographics
NPI:1013020395
Name:STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity type:Organization
Organization Name:STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE CFO - CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-834-5157
Mailing Address - Street 1:PO BOX 11407, DEPT 2130
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2130
Mailing Address - Country:US
Mailing Address - Phone:662-834-1321
Mailing Address - Fax:662-834-5240
Practice Address - Street 1:239 BOWLING GREEN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-5167
Practice Address - Country:US
Practice Address - Phone:662-834-1321
Practice Address - Fax:662-834-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-199-S-2207P00000X, 207R00000X
MS11-119-S-2207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02544Medicare ID - Type UnspecifiedPART B (CAHABA)