Provider Demographics
NPI:1356448591
Name:COPIAH COUNTY MEDICAL CENTER
Entity Type:Organization
Organization Name:COPIAH COUNTY MEDICAL CENTER
Other - Org Name:HAZLEHURST CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KORTNEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-574-7200
Mailing Address - Street 1:27190 HWY 28
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083
Mailing Address - Country:US
Mailing Address - Phone:601-574-7200
Mailing Address - Fax:601-894-2514
Practice Address - Street 1:213 CALDWELL DR
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083
Practice Address - Country:US
Practice Address - Phone:601-894-2514
Practice Address - Fax:601-894-2514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COPIAH COUNTY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113908Medicaid
MS00116996Medicaid
MS00015329Medicaid
MS09013707Medicaid
MS00119484Medicaid
MS00012939Medicaid
MS00011981Medicaid
MS00122024Medicaid
MS00011981Medicaid
MS080000202Medicare ID - Type UnspecifiedROBERT WALKER, MD
MS00015329Medicaid
MS080001626Medicare ID - Type UnspecifiedKEN WHITTINGTON, MD
MS00122024Medicaid
MS00116996Medicaid
MS011798911Medicare ID - Type UnspecifiedJOHN LONG MD