Healthcare Provider Details

I. General information

NPI: 1518176445
Provider Name (Legal Business Name): KILMICHAEL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LAMAR AVE.
KILMICHAEL MS
39747-0188
US

IV. Provider business mailing address

PO BOX 188
KILMICHAEL MS
39747-0188
US

V. Phone/Fax

Practice location:
  • Phone: 662-262-4311
  • Fax: 662-262-5586
Mailing address:
  • Phone: 662-262-4311
  • Fax: 662-262-5586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12496
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16482
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number000010138
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number10138
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR605859
License Number StateMS
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR504696
License Number StateMS
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMS06391
License Number StateMS

VIII. Authorized Official

Name: MR. CALVIN DEXTER JOHNSON II
Title or Position: ADMINISTRATOR
Credential:
Phone: 662-262-4311