Organization
CLAIB CTY HSP PRO FEES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RAY L SHOEMAKER (CEO)
(662) 321-1155
Entity
Organization
Contact information
Practice address
123 MCCOMB AVE, PORT GIBSON, MS 39150-2915
(601) 437-5141
(601) 437-8547
Mailing address
123 MCCOMB AVE, P O BOX 1004, PORT GIBSON, MS 39150-2915
(601) 437-5141
(601) 437-8547
Taxonomy
Speciality
Code
Description
License number
State
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
—
—
207RC0000X
Cardiovascular Disease Physician
—
—
2085R0202X
Diagnostic Radiology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000019140
PROF FEE
MS
05
—
09013195
—
MS
05
—
09013196
—
MS
05
—
09013197
—
MS
Enumeration date
03/29/2007
Last updated
06/14/2010
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