Provider Demographics
NPI:1407095060
Name:TYLER HOLMES MEMORIAL HOSPITAL XRAY
Entity Type:Organization
Organization Name:TYLER HOLMES MEMORIAL HOSPITAL XRAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:R
Authorized Official - Middle Name:M
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-283-6127
Mailing Address - Street 1:409 TYLER HOLMES DR
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1521
Mailing Address - Country:US
Mailing Address - Phone:662-283-4114
Mailing Address - Fax:662-283-4640
Practice Address - Street 1:409 TYLER HOLMES DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1521
Practice Address - Country:US
Practice Address - Phone:662-283-4114
Practice Address - Fax:662-283-4640
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TYLER HOLMES MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012469Medicaid
MS000019156OtherBLUE CROSS
MSC00073OtherMEDICARE PTAN