Provider Demographics
NPI:1225247505
Name:JEFFERSON COUNTY HOSPITAL
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HOSPITAL
Other - Org Name:EMERGENCY ROOM PHYSICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-786-3401
Mailing Address - Street 1:870 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069
Mailing Address - Country:US
Mailing Address - Phone:601-786-3401
Mailing Address - Fax:601-786-3400
Practice Address - Street 1:870 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-3401
Practice Address - Fax:601-786-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14997207Q00000X
MS07965207QH0002X
MS16670207RH0002X
MS14721207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Not Answered207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty