Provider Demographics
NPI:1295704922
Name:GREENWOOD LEFLORE HOSPITAL
Entity type:Organization
Organization Name:GREENWOOD LEFLORE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DAWNE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-459-2603
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1410
Mailing Address - Country:US
Mailing Address - Phone:662-459-1207
Mailing Address - Fax:
Practice Address - Street 1:1413 STRONG AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4035
Practice Address - Country:US
Practice Address - Phone:662-459-1207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENWOOD LEFLORE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-15
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07004257Medicaid
C02768Medicare PIN
CJ9955OtherMEDICARE RAILROAD
MS258552OtherMEDICARE-RHC
MS260000615OtherPART B (DR. CLYDE GLENN)
MS721374685OtherBCBS
MS00120179Medicaid