=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972603819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COPIAH COUNTY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 BO BO DR
-----------------------------------------------------
City | CRYSTAL SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-892-2225
-----------------------------------------------------
Fax | 601-892-1456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27190 HWY 28
-----------------------------------------------------
City | HAZLEHURST
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-574-7000
-----------------------------------------------------
Fax | 601-892-1456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KORTNEY M. GADDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-574-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------