Provider Demographics
NPI:1598769044
Name:COVINGTON COUNTY HOSPITAL
Entity Type:Organization
Organization Name:COVINGTON COUNTY HOSPITAL
Other - Org Name:CCH CLINIC FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-698-0328
Mailing Address - Street 1:P.O. BOX 2499
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428-2499
Mailing Address - Country:US
Mailing Address - Phone:601-765-3180
Mailing Address - Fax:601-765-2808
Practice Address - Street 1:301 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-4225
Practice Address - Country:US
Practice Address - Phone:601-765-3180
Practice Address - Fax:601-765-2808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25D0864691OtherCLIA
MS09015963Medicaid
C02717Medicare ID - Type Unspecified
MS09015963Medicaid
MSC02717Medicare PIN