# STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
- **Other names:** UNIVERSITY OF MISSISSIPPI MEDICAL CENTER-GRENADA SPECIALTY CLINIC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1932538527
- **Legal business name:** STATE OF MISSISSIPPI - UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
- **Authorized official:** MR. KEVIN COOK (CEO)
- **Authorized official phone:** (601) 984-4113

## Contact information

- **Practice address:** 965 AVENT DR, SUITE 100A, GRENADA, MS 38901-5045
- **Practice address phone:** (662) 227-7444
- **Practice address fax:** (662) 227-7443
- **Mailing address:** 2500 N STATE ST, JACKSON, MS 39216-4500
- **Mailing address phone:** (601) 984-4113

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 11/05/2013
- **Last updated:** 03/06/2014