MEDICARE: BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NC0060X	Critical Access Hospital

General Provider Information

NPI Number	:	1104814169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC

Provider Business Mailing Address
First Line	:	PO BOX 1039
Second Line	:
City	:	ACKERMAN
State	:	MS
Zip	:	39735-1039
Country	:	US
Telephone Number	:	662-285-6235
Fax Number	:	662-285-2516

Provider Business Practice Location Address
First Line	:	311 E CHERRY ST
Second Line	:
City	:	ACKERMAN
State	:	MS
Zip	:	39735-9795
Country	:	US
Telephone Number	:	662-285-6235
Fax Number	:	662-285-2516

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RAY SHOEMAKER
Credential	:
Telephone Number	:	662-285-6235

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/09/2008

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