Basic Information
Provider Information | |||||||||
NPI: | 1316180748 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MISSISSIPPI COUNTY HOSPITAL SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GREAT RIVER MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 108 | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723160108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708387300 | ||||||||
FaxNumber: | 8708387493 | ||||||||
Practice Location | |||||||||
Address1: | 1520 NORTH DIVISION | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723151448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708387300 | ||||||||
FaxNumber: | 8708387493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2009 | ||||||||
LastUpdateDate: | 11/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAYMER | ||||||||
AuthorizedOfficialFirstName: | CHRIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO/CNO | ||||||||
AuthorizedOfficialTelephone: | 8708387460 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | N |   | Hospitals | General Acute Care Hospital |   | 282NR1301X |   |   | N |   | Hospitals | General Acute Care Hospital | Rural | 282N00000X | AR4562 | AR | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 010158103 | 05 | MO |   | MEDICAID | 178791105 | 05 | AR |   | MEDICAID |