Provider Demographics
NPI:1518275544
Name:WALTHALL RURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:WALTHALL RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-288-7000
Mailing Address - Street 1:POST OFFICE BOX 677
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2025
Mailing Address - Country:US
Mailing Address - Phone:601-876-5303
Mailing Address - Fax:601-876-0653
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2020
Practice Address - Country:US
Practice Address - Phone:601-876-5303
Practice Address - Fax:601-876-0653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13883207Q00000X
MS11133207Q00000X
MS10220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07552559Medicaid
MS302G707791OtherMEDICARE PTAN