Provider Demographics
NPI:1003148859
Name:FIELD MEMORIAL COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:FIELD MEMORIAL COMMUNITY HOSPITAL
Other - Org Name:FMCH GLOSTER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:NETTERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-645-5221
Mailing Address - Street 1:270 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631
Mailing Address - Country:US
Mailing Address - Phone:601-645-5221
Mailing Address - Fax:
Practice Address - Street 1:434 N CAPTAIN GLOSTER DR
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:MS
Practice Address - Zip Code:39638-3401
Practice Address - Country:US
Practice Address - Phone:601-224-4711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445096Medicaid