Basic Information
| Provider Information | |||||||||
| NPI: | 1194009019 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSISSIPPI COUNTY HOSPITAL SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GREAT RIVER MEDICAL CENTER-SENIOR CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723151448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387460 | ||||||||
| FaxNumber: | 8708387493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723151448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387460 | ||||||||
| FaxNumber: | 8708387493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAYMER | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | COO/CNO | ||||||||
| AuthorizedOfficialTelephone: | 8708387460 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSISSIPPI COUNTY HOSPITAL SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | AR4562 | AR | Y | Hospital Units | Psychiatric Unit |
No ID Information.