Provider Demographics
NPI:1316180748
Name:MISSISSIPPI COUNTY HOSPITAL SYSTEM
Entity Type:Organization
Organization Name:MISSISSIPPI COUNTY HOSPITAL SYSTEM
Other - Org Name:GREAT RIVER MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/CNO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-838-7460
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72316-0108
Mailing Address - Country:US
Mailing Address - Phone:870-838-7300
Mailing Address - Fax:870-838-7493
Practice Address - Street 1:1520 NORTH DIVISION
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1448
Practice Address - Country:US
Practice Address - Phone:870-838-7300
Practice Address - Fax:870-838-7493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X, 282NR1301X
ARAR4562282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010158103Medicaid
AR178791105Medicaid
040069Medicare PIN