Basic Information
| Provider Information | |||||||||
| NPI: | 1366685992 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMC-MISSISSIPPI COUNTY HOSPITAL SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SMC REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108 | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723160108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387300 | ||||||||
| FaxNumber: | 8708387493 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W LEE AVE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723703001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708387000 | ||||||||
| FaxNumber: | 8708387493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2009 | ||||||||
| LastUpdateDate: | 11/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| 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 | 282NC0060X | N | Hospitals | General Acute Care Hospital | Critical Access | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | AR4563 | AR | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 178790105 | 05 | AR | MEDICAID |