Healthcare Provider Details

I. General information

NPI: 1144204561
Provider Name (Legal Business Name): KILMICHAEL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LAMAR AVENUE
KILMICHAEL MS
39747-0188
US

IV. Provider business mailing address

PO BOX 188 301 LAMAR AVENUE
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 TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number21183
License Number StateMS

VIII. Authorized Official

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