Basic Information
Provider Information | |||||||||
NPI: | 1104075860 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TYLER HOLMES MEMORIAL HOSPITAL EKG | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 409 TYLER HOLMES DR | ||||||||
Address2: |   | ||||||||
City: | WINONA | ||||||||
State: | MS | ||||||||
PostalCode: | 389671521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6622834114 | ||||||||
FaxNumber: | 6622834640 | ||||||||
Practice Location | |||||||||
Address1: | 409 TYLER HOLMES DR | ||||||||
Address2: |   | ||||||||
City: | WINONA | ||||||||
State: | MS | ||||||||
PostalCode: | 389671521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6622834114 | ||||||||
FaxNumber: | 6622834640 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2008 | ||||||||
LastUpdateDate: | 02/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TYLER | ||||||||
AuthorizedOfficialFirstName: | R | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 6622836127 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TYLER HOLMES MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | C00070 | 01 | MS | MEDICARE PTAN | OTHER | 000019156 | 01 | MS | BLUE CROSS | OTHER | 09012469 | 05 | MS |   | MEDICAID |