NPIMap

Organization Active NPI

Ellisville State School

  • Health Maintenance Organization
  • Ellisville, MS
National Provider Identifier
1720181191
Registry record updated Jun 12, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Health Maintenance OrganizationTaxonomy code 302R00000X
License
233 Issued in MS
Legal business name
ELLISVILLE STATE SCHOOL
Practice address
1101 Highway 11 S
Ellisville, MS 39437-4443
Phone
(601) 477-9384
Fax
(601) 477-5700
NPI assigned
Sep 7, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Pam K Young
Title
Accounting Auditor 1
Phone
(601) 477-5606

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Health Maintenance Organization 302R00000X 233 MS Primary

Addresses

Primary practice location

1101 Highway 11 S
Ellisville, MS 39437-4443

Mailing address

1101 Highway 11 S
Ellisville, MS 39437-4443
Phone (601) 477-9384

Other identifiers 1

IdentifierTypeStateIssuer
00021831MedicaidMS

Other names 1

  • Clover Circle ICF/MR Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Ellisville State School9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1157587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213228800000",
    "number": "1720181191",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 HIGHWAY 11 S",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394374443",
            "telephone_number": "601-477-9384",
            "fax_number": "601-477-5700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 HIGHWAY 11 S",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394374443",
            "telephone_number": "601-477-9384",
            "fax_number": "601-477-5700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELLISVILLE STATE SCHOOL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-07",
        "last_updated": "2008-06-12",
        "status": "A",
        "authorized_official_last_name": "YOUNG",
        "authorized_official_first_name": "PAM",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "ACCOUNTING AUDITOR 1",
        "authorized_official_telephone_number": "601-477-5606",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "302R00000X",
            "taxonomy_group": "",
            "desc": "Health Maintenance Organization",
            "state": "MS",
            "license": "233",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00021831",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clover Circle ICF/MR",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ellisville, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.