Provider Demographics
NPI:1154390854
Name:GREENWOOD LEFLORE HOSPITAL
Entity type:Organization
Organization Name:GREENWOOD LEFLORE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-459-7000
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:ATTN CLINIC ADMINISTRATION
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1410
Mailing Address - Country:US
Mailing Address - Phone:662-459-7189
Mailing Address - Fax:662-459-1147
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:ATTN CLINIC ADMINISTRATION
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:662-459-7189
Practice Address - Fax:662-459-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014025Medicaid
MS=========OtherBCBS
MSC02772Medicare ID - Type Unspecified
MS253429Medicare PIN