Provider Demographics
NPI:1285776328
Name:ALCORN STATE UNIVERSITY
Entity type:Organization
Organization Name:ALCORN STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-304-4375
Mailing Address - Street 1:15 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-5364
Mailing Address - Country:US
Mailing Address - Phone:601-304-4334
Mailing Address - Fax:601-304-4355
Practice Address - Street 1:15 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5364
Practice Address - Country:US
Practice Address - Phone:601-304-4375
Practice Address - Fax:601-304-4355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALCORN STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014990Medicare ID - Type Unspecified