Basic Information
| Provider Information | |||||||||
| NPI: | 1730367459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TYLER HOLMES MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CROSSROADS FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 416 TYLER HOLMES DR | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389671522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622834114 | ||||||||
| FaxNumber: | 6622834640 | ||||||||
| Practice Location | |||||||||
| Address1: | 416 TYLER HOLMES DR | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389671522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622834114 | ||||||||
| FaxNumber: | 6622834640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TYLER | ||||||||
| AuthorizedOfficialFirstName: | ROSAMOND | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6622836127 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TYLER HOLMES MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 08203508 | 05 | MS | MEDICAID | 8009711 | 05 | MS | MEDICAID |