1972603819 NPI number — COPIAH COUNTY MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972603819 NPI number — COPIAH COUNTY MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COPIAH COUNTY MEDICAL CENTER
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:
CRYSTAL SPRINGS CLINIC
Provider Other Organization Name Type Code:
3
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:
1972603819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27190 HWY 28
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLEHURST
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-574-7200
Provider Business Mailing Address Fax Number:
601-892-1456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 BO BO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-892-1456
Provider Business Practice Location Address Fax Number:
601-892-1456
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GADDY
Authorized Official First Name:
KORTNEY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
601-574-7200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09014049 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00116996 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00012939 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00015329 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00011981 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00113908 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00119484 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00122024 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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