Provider Demographics
NPI:1639236383
Name:YALOBUSHA GENERAL HOSPITAL
Entity Type:Organization
Organization Name:YALOBUSHA GENERAL HOSPITAL
Other - Org Name:COFFEEVILLE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-473-1411
Mailing Address - Street 1:14430 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COFFEEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38922-2590
Mailing Address - Country:US
Mailing Address - Phone:662-675-2500
Mailing Address - Fax:662-675-2501
Practice Address - Street 1:14430 MAIN ST
Practice Address - Street 2:
Practice Address - City:COFFEEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38922-2590
Practice Address - Country:US
Practice Address - Phone:662-675-2500
Practice Address - Fax:662-675-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9014717Medicaid
MS00120194Medicaid
MS9014717Medicaid
08264669Medicare Oscar/Certification
P96376Medicare UPIN
500002312Medicare Oscar/Certification