NPIMap

Organization Active NPI

Walthal Rural Health Clinic

  • Internal Medicine Physician
  • Tylertown, MS
National Provider Identifier
1144530403
Registry record updated Apr 11, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
10220 Issued in MS
Legal business name
WALTHAL RURAL HEALTH CLINIC
Practice address
200 Hospital Dr
Tylertown, MS 39667-2020
Phone
(601) 876-5303
NPI assigned
Oct 20, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 11, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Evan Dillard
Title
President/Ceo
Phone
(601) 288-4490

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X 10220 MS Primary

Addresses

Primary practice location

200 Hospital Dr
Tylertown, MS 39667-2020

Mailing address

PO Box 677
Tylertown, MS 39667-0677

Other identifiers 2

IdentifierTypeStateIssuer
302G707791OtherMSMEDICARE PTAN
07552559MedicaidMS

Other names 1

  • Tylertown Internal Medicine Clinic Doing business as

National Provider Directory

National Provider Directory

Locations

251 Hospital Dr
Ste A
Tylertown, MS 39667
Phone (601) 876-0800

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1287532800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1365638400000",
    "number": "1144530403",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 677",
            "city": "TYLERTOWN",
            "state": "MS",
            "postal_code": "396670677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 HOSPITAL DR",
            "city": "TYLERTOWN",
            "state": "MS",
            "postal_code": "396672020",
            "telephone_number": "601-876-5303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALTHAL RURAL HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-20",
        "last_updated": "2013-04-11",
        "status": "A",
        "authorized_official_last_name": "DILLARD",
        "authorized_official_first_name": "EVAN",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "601-288-4490"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "MS",
            "license": "10220",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "302G707791",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07552559",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tylertown Internal Medicine Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tylertown, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.