Healthcare Provider Details

I. General information

NPI: 1558480491
Provider Name (Legal Business Name): CLAIB CTY HSP PRO FEES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 06/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MCCOMB AVE
PORT GIBSON MS
39150-2915
US

IV. Provider business mailing address

123 MCCOMB AVE P O BOX 1004
PORT GIBSON MS
39150-2915
US

V. Phone/Fax

Practice location:
  • Phone: 601-437-5141
  • Fax: 601-437-8547
Mailing address:
  • Phone: 601-437-5141
  • Fax: 601-437-8547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RAY L SHOEMAKER
Title or Position: CEO
Credential:
Phone: 662-321-1155