Basic Information
| Provider Information | |||||||||
| NPI: | 1770715450 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORREST COUNTY GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEARL RIVER FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 S 28TH AVE STE 326 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012881823 | ||||||||
| FaxNumber: | 6012884360 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 HIGHWAY 11 S | ||||||||
| Address2: | |||||||||
| City: | POPLARVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394702625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014038284 | ||||||||
| FaxNumber: | 6014038283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2009 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HESTER | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6012884225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORREST COUNTY GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 21087 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.