Provider Demographics
NPI:1104904457
Name:CLAIBORNE COUNTY HOSPITAL
Entity type:Organization
Organization Name:CLAIBORNE COUNTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-321-1155
Mailing Address - Street 1:123 MCCOMB AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-1004
Mailing Address - Country:US
Mailing Address - Phone:601-437-5141
Mailing Address - Fax:601-437-5166
Practice Address - Street 1:123 MCCOMB AVENUE
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-1004
Practice Address - Country:US
Practice Address - Phone:601-437-5141
Practice Address - Fax:601-437-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00029140Medicaid
MS00029140Medicaid