Healthcare Provider Details

I. General information

NPI: 1053450320
Provider Name (Legal Business Name): PEARL RIVER COUNTY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 WEST MOODY STREET
POPLARVILLE MS
39470
US

IV. Provider business mailing address

PO BOX 392
POPLARVILLE MS
39470
US

V. Phone/Fax

Practice location:
  • Phone: 601-795-4543
  • Fax: 601-795-4238
Mailing address:
  • Phone: 601-795-4543
  • Fax: 601-795-4238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number21087
License Number StateMS

VIII. Authorized Official

Name: MR. MICHAEL BOLEWARE
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-795-4543