Basic Information
| Provider Information | |||||||||
| NPI: | 1407803570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENWOOD LEFLORE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1410 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389351410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597149 | ||||||||
| FaxNumber: | 6624591159 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389304030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597149 | ||||||||
| FaxNumber: | 6624591159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6624597149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREENWOOD LEFLORE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 11065 | MS | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 00020025 | 05 | MS | MEDICAID |