Healthcare Provider Details

I. General information

NPI: 1487863692
Provider Name (Legal Business Name): KILMICHAEL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LAMAR AVE
KILMICHAEL MS
39747
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number21-183
License Number StateMS

VIII. Authorized Official

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