Provider Demographics
NPI:1245512417
Name:WALTHALL GENERAL HOSPITAL
Entity type:Organization
Organization Name:WALTHALL GENERAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-288-4225
Mailing Address - Street 1:PO BOX 15722
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404
Mailing Address - Country:US
Mailing Address - Phone:601-288-1889
Mailing Address - Fax:601-288-1848
Practice Address - Street 1:100 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667
Practice Address - Country:US
Practice Address - Phone:601-876-2122
Practice Address - Fax:601-876-0432
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORREST GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-14
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-257207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013588Medicaid