Healthcare Provider Details

I. General information

NPI: 1710238324
Provider Name (Legal Business Name): CLAIBORNE COUNTY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 01/30/2014
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

PO BOX 1004 123 MCCOMB AVENUE
PORT GIBSON MS
39150-1004
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number26-276
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number26-276
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26-276
License Number StateMS

VIII. Authorized Official

Name: MR. CHARLIE NORRELL
Title or Position: PRESIDENT
Credential:
Phone: 601-437-5141