Provider Demographics
NPI:1457321036
Name:PHC-CLEVELAND LLC
Entity Type:Organization
Organization Name:PHC-CLEVELAND LLC
Other - Org Name:BOLIVAR MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-253-5121
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4536
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:
Practice Address - Street 1:901 E SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2833
Practice Address - Country:US
Practice Address - Phone:662-846-0061
Practice Address - Fax:662-846-2380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16224282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0220606Medicaid
MS250093Medicare Oscar/Certification