1730367459 NPI number — TYLER HOLMES MEMORIAL HOSPITAL

Table of content: (NPI 1730367459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730367459 NPI number — TYLER HOLMES MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TYLER HOLMES MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CROSSROADS FAMILY MEDICINE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730367459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 WOODLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINONA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38967-1530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-283-8205
Provider Business Mailing Address Fax Number:
662-283-6747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 WOODLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINONA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38967-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-283-8205
Provider Business Practice Location Address Fax Number:
662-283-6747
Provider Enumeration Date:
02/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LYONS
Authorized Official First Name:
MEMORIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
662-283-6119

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008203508 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2070889 . This is a "WELLCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 8009711 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005330334 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007870552 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1497164446 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1730367459 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1730550419 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 200007660 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2163489 . This is a "WELLCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 08203508 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1659550127 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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