Provider Demographics
NPI:1720253735
Name:HUMPHREYS COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HUMPHREYS COUNTY MEMORIAL HOSPITAL
Other - Org Name:CHURCH STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-321-1155
Mailing Address - Street 1:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0510
Mailing Address - Country:US
Mailing Address - Phone:662-247-3831
Mailing Address - Fax:662-247-4114
Practice Address - Street 1:500 CCC ROAD
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-0000
Practice Address - Country:US
Practice Address - Phone:662-247-3831
Practice Address - Fax:662-247-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
253485Medicare PIN