Provider Demographics
NPI:1609973056
Name:ALLIANCE HEALTHCARE SYSTEM
Entity type:Organization
Organization Name:ALLIANCE HEALTHCARE SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:GOODMAN
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-252-1599
Mailing Address - Street 1:538 ASH RD.
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-5040
Mailing Address - Country:US
Mailing Address - Phone:662-252-1599
Mailing Address - Fax:
Practice Address - Street 1:538 J. M. ASH RD.
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3238
Practice Address - Country:US
Practice Address - Phone:662-252-1599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114188Medicaid
MSQ34863Medicare UPIN
MS50001715Medicare ID - Type Unspecified