Provider Demographics
NPI:1518176445
Name:KILMICHAEL HOSPITAL
Entity Type:Organization
Organization Name:KILMICHAEL HOSPITAL
Other - Org Name:KILMICHAEL HOSPITAL PROFESSIONAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:DEXTER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:662-262-4311
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:KILMICHAEL
Mailing Address - State:MS
Mailing Address - Zip Code:39747-0188
Mailing Address - Country:US
Mailing Address - Phone:662-262-4311
Mailing Address - Fax:662-262-5586
Practice Address - Street 1:301 LAMAR AVE.
Practice Address - Street 2:
Practice Address - City:KILMICHAEL
Practice Address - State:MS
Practice Address - Zip Code:39747-0188
Practice Address - Country:US
Practice Address - Phone:662-262-4311
Practice Address - Fax:662-262-5586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12496207Q00000X
MS16482207Q00000X
MS000010138207RC0000X
MS10138207RC0000X
MSMS063912085R0202X
MSR605859363L00000X
MSR504696363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03335377Medicaid
MS19147OtherPROFESSIONAL COMPONENT
MS19147OtherPROFESSIONAL COMPONENT