Basic Information
| Provider Information | |||||||||
| NPI: | 1407095060 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TYLER HOLMES MEMORIAL HOSPITAL XRAY | ||||||||
| 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: | 02/05/2009 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
| 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 | 09012469 | 05 | MS | MEDICAID | 000019156 | 01 | MS | BLUE CROSS | OTHER | C00073 | 01 | MS | MEDICARE PTAN | OTHER |