Provider Demographics
NPI:1366628927
Name:PATIENTS' CHOICE MEDICAL CENTER OF HUMPHREYS COUNTY, LLC
Entity Type:Organization
Organization Name:PATIENTS' CHOICE MEDICAL CENTER OF HUMPHREYS COUNTY, LLC
Other - Org Name:CHURCH STREET CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-247-3874
Mailing Address - Street 1:500 CCC ROAD
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0510
Mailing Address - Country:US
Mailing Address - Phone:662-247-3874
Mailing Address - Fax:
Practice Address - Street 1:500 CCC RD
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038
Practice Address - Country:US
Practice Address - Phone:662-247-3874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RURAL HEALTHCARE DEVELOPERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-14
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014821Medicaid