Provider Demographics
NPI:1609822659
Name:WALTHALL COUNTY GENERAL HOSPITAL
Entity Type:Organization
Organization Name:WALTHALL COUNTY GENERAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:LIN
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:CHE
Authorized Official - Phone:601-876-2122
Mailing Address - Street 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2022
Mailing Address - Country:US
Mailing Address - Phone:601-876-2122
Mailing Address - Fax:601-222-0432
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2022
Practice Address - Country:US
Practice Address - Phone:601-876-2122
Practice Address - Fax:601-222-0432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-257282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0020208Medicaid
MS25M324Medicare ID - Type UnspecifiedMEDICARE GER. PSY. NUMBER
MS251324Medicare ID - Type UnspecifiedMEDICARE NUMBER
MS0020208Medicaid
MSC02151Medicare ID - Type UnspecifiedWALTHALL ER PHYSICIANS #