Healthcare Provider Details

I. General information

NPI: 1982641593
Provider Name (Legal Business Name): GEORGE COUNTY HOSPITAL- CRNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 WINTER ST
LUCEDALE MS
39452-6603
US

IV. Provider business mailing address

859 WINTER ST
LUCEDALE MS
39452-6603
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-3161
  • Fax: 601-947-9206
Mailing address:
  • Phone: 601-947-3161
  • Fax: 601-947-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number11-166
License Number StateMS

VIII. Authorized Official

Name: MR. PAUL A GARDNER
Title or Position: CEO
Credential:
Phone: 601-947-9148