# PHYSICIAN GROUP

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** EAST MISSISSIPPI STATE HOSPITAL
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1558679902
- **Legal business name:** EAST MISSISSIPPI STATE HOSPITAL
- **Authorized official:** DR. CHARLES CARLISLE (HOSPITAL DIRECTOR)
- **Authorized official phone:** (601) 581-7877

## Contact information

- **Practice address:** 4555 HIGHLAND PARK DR, MERIDIAN, MS 39307-5429
- **Practice address phone:** (601) 581-7969
- **Practice address fax:** (601) 581-7676
- **Mailing address:** PO BOX 4128, MERIDIAN, MS 39304-4128
- **Mailing address phone:** (601) 581-7969
- **Mailing address fax:** (601) 581-7676

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM1300X | Multi-Specialty Clinic/Center | 36-136 | MS | Yes |

## Other

- **Enumeration date:** 09/20/2010
- **Last updated:** 05/12/2020