Provider Demographics
NPI:1619088531
Name:PHYSICIANS HOSPICE, INC
Entity Type:Organization
Organization Name:PHYSICIANS HOSPICE, INC
Other - Org Name:CHARITY HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-326-3500
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-0387
Mailing Address - Country:US
Mailing Address - Phone:662-326-7323
Mailing Address - Fax:662-326-6348
Practice Address - Street 1:340 GETWELL ST
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-9785
Practice Address - Country:US
Practice Address - Phone:662-326-7323
Practice Address - Fax:662-326-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS055251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0770431Medicaid
MS0770431Medicaid