Provider Demographics
NPI:1730367459
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:MRS
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 1:702 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1530
Mailing Address - Country:US
Mailing Address - Phone:662-283-8205
Mailing Address - Fax:662-283-6747
Practice Address - Street 1:702 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1530
Practice Address - Country:US
Practice Address - Phone:662-283-8205
Practice Address - Fax:662-283-6747
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TYLER HOLMES MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-05
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS008203508Medicaid
MS2070889OtherWELLCARE
MS8009711Medicaid
MS005330334Medicaid
MS007870552Medicaid
MS1497164446OtherNPI
MS1730367459OtherNPI
MS1730550419OtherNPI
MS200007660Medicaid
MS2163489OtherWELLCARE
MS08203508Medicaid
MS1659550127OtherNPI