Provider Demographics
NPI:1093930638
Name:WAYNE GENERAL HOSPITAL
Entity Type:Organization
Organization Name:WAYNE GENERAL HOSPITAL
Other - Org Name:WAYNE GENERAL CRNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-735-5151
Mailing Address - Street 1:950 MATTHEW DR
Mailing Address - Street 2:P O BOX 1249
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2567
Mailing Address - Country:US
Mailing Address - Phone:601-735-5151
Mailing Address - Fax:601-735-7168
Practice Address - Street 1:950 MATTHEW DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2567
Practice Address - Country:US
Practice Address - Phone:601-735-5151
Practice Address - Fax:601-735-7168
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE GENERAL HOSPTIAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-288367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012424Medicaid
MSC00816Medicare PIN