Provider Demographics
NPI:1982641593
Name:GEORGE COUNTY HOSPITAL- CRNA
Entity Type:Organization
Organization Name:GEORGE COUNTY HOSPITAL- CRNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-947-9148
Mailing Address - Street 1:859 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-6603
Mailing Address - Country:US
Mailing Address - Phone:601-947-3161
Mailing Address - Fax:601-947-9206
Practice Address - Street 1:859 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6603
Practice Address - Country:US
Practice Address - Phone:601-947-3161
Practice Address - Fax:601-947-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-166282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000019120AOtherBC BS OF MS
MSC00879OtherMEDICAE GROUP NUMBER
MS09013665Medicaid