Provider Demographics
NPI:1982659405
Name:BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC
Entity Type:Organization
Organization Name:BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC
Other - Org Name:CHOCTAW COUNTY MEDICAL CENTER RHC-WEIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-285-6235
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-1039
Mailing Address - Country:US
Mailing Address - Phone:662-285-6235
Mailing Address - Fax:662-285-2516
Practice Address - Street 1:547 FRONT ST.
Practice Address - Street 2:
Practice Address - City:WEIR
Practice Address - State:MS
Practice Address - Zip Code:39772
Practice Address - Country:US
Practice Address - Phone:662-547-9697
Practice Address - Fax:662-547-9698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS258533Medicare ID - Type Unspecified