=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194057943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIELD MEMORIAL COMMUNITY HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2010
-----------------------------------------------------
Last Update Date | 02/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 BANK ST
-----------------------------------------------------
City | WOODVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39669-6000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-888-3421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 639
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39631-0639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-645-5221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JEREMY CHAD NETTERVILLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-645-5221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------