Healthcare Provider Details

I. General information

NPI: 1194734913
Provider Name (Legal Business Name): COMMUNITY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W RATLIFF STREET
LUCEDALE MS
39452-6537
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8181
  • Fax: 601-947-4411
Mailing address:
  • Phone: 601-947-8181
  • Fax: 601-947-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN RUTLEDGE
Title or Position: BILLING MANAGER
Credential:
Phone: 601-947-1330