Organization
WALTHAL RURAL HEALTH CLINIC
Active
Other names
Tylertown Internal Medicine Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
EVAN DILLARD (PRESIDENT/CEO)
(601) 288-4490
Entity
Organization
Contact information
Practice address
200 HOSPITAL DR, TYLERTOWN, MS 39667-2020
(601) 876-5303
Mailing address
PO BOX 677, TYLERTOWN, MS 39667-0677
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
10220
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07552559
—
MS
01
—
302G707791
MEDICARE PTAN
MS
Enumeration date
10/20/2010
Last updated
04/11/2013
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