MEDICARE: PICAYUNE RURAL HEALTH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	13678	MS
2	363L00000X	Nurse Practitioner	R767181	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700983913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PICAYUNE RURAL HEALTH CLINIC

Provider Business Mailing Address
First Line	:	317 N MAIN ST
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466-3313
Country	:	US
Telephone Number	:	601-799-5577
Fax Number	:	601-799-5444

Provider Business Practice Location Address
First Line	:	317 N MAIN ST
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466-3313
Country	:	US
Telephone Number	:	601-799-5577
Fax Number	:	601-799-5444

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTA KAY HODGE
Credential	:	FNP
Telephone Number	:	601-799-5577

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/18/2009

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Directions to “PICAYUNE RURAL HEALTH CLINIC ” Practice Location

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