Provider Demographics
NPI:1548883481
Name:TYLER HOLMES MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:TYLER HOLMES MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEMORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-283-6119
Mailing Address - Street 1:409 TYLER HOLMES DR
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1521
Mailing Address - Country:US
Mailing Address - Phone:662-283-4114
Mailing Address - Fax:662-283-6125
Practice Address - Street 1:504 GEORGE STREET
Practice Address - Street 2:
Practice Address - City:NORTH CARROLLTON
Practice Address - State:MS
Practice Address - Zip Code:38947
Practice Address - Country:US
Practice Address - Phone:662-989-1574
Practice Address - Fax:662-989-1569
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TYLER HOLMES MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-27
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS001608351Medicaid
MS001709891Medicaid
MS1700426707OtherNPI
MS1497164446OtherNPI
MS2466404OtherWELLCARE
MS000015590Medicaid
MS200007660Medicaid
MS1548883481OtherNPI
MS1568502714OtherNPI