Provider Demographics
NPI:1710238324
Name:CLAIBORNE COUNTY HOSPITAL
Entity Type:Organization
Organization Name:CLAIBORNE COUNTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-437-5141
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:123 MCCOMB AVENUE
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-1004
Mailing Address - Country:US
Mailing Address - Phone:601-437-5141
Mailing Address - Fax:
Practice Address - Street 1:123 MCCOMB AVE
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2915
Practice Address - Country:US
Practice Address - Phone:601-437-5141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26-276207PE0004X, 207RC0000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013195Medicaid