Healthcare Provider Details

I. General information

NPI: 1609822659
Provider Name (Legal Business Name): WALTHALL COUNTY GENERAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR
TYLERTOWN MS
39667-2022
US

IV. Provider business mailing address

100 HOSPITAL DR
TYLERTOWN MS
39667-2022
US

V. Phone/Fax

Practice location:
  • Phone: 601-876-2122
  • Fax: 601-222-0432
Mailing address:
  • Phone: 601-876-2122
  • Fax: 601-222-0432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number11-257
License Number StateMS

VIII. Authorized Official

Name: MR. JIMMY LIN GRAVES
Title or Position: ADMINISTRATOR
Credential: CHE
Phone: 601-876-2122