NPIMap

Organization Active NPI

Copiah County Medical Center

Doing business as Hazlehurst Clinic

  • Family Medicine Physician
  • Hazlehurst, MS
National Provider Identifier
1356448591
Registry record updated Sep 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
COPIAH COUNTY MEDICAL CENTER
Doing business as
Hazlehurst Clinic
Practice address
213 Caldwell Dr
Hazlehurst, MS 39083
Phone
(601) 894-2514
Fax
(601) 894-2514
NPI assigned
Sep 20, 2006
Last updated
Sep 22, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
COPIAH COUNTY MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 22, 2022

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

Authorized official

Name
Kortney M. Gaddy
Title
Cfo
Phone
(601) 574-7200

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X MS Primary

Addresses

Primary practice location

213 Caldwell Dr
Hazlehurst, MS 39083

Mailing address

27190 Hwy 28
Hazlehurst, MS 39083
Phone (601) 574-7200

Other identifiers 8

IdentifierTypeStateIssuer
00119484MedicaidMS
00122024MedicaidMS
00011981MedicaidMS
00113908MedicaidMS
00116996MedicaidMS
00012939MedicaidMS
09013707MedicaidMS
00015329MedicaidMS

Other names 1

  • Hazlehurst Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080714000378 MS Part B Supplier - Clinic/Group Practice 3577569862 Receives reassigned benefits from 10 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Crystal Springs, MS; Hazlehurst, MS

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Kliesch Med Assoc PA7 organizations share this tax ID, including this one
Part of
Kliesch Med Assoc PA

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663804800000",
    "number": "1356448591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "27190 HWY 28",
            "city": "HAZLEHURST",
            "state": "MS",
            "postal_code": "39083",
            "telephone_number": "601-574-7200",
            "fax_number": "601-894-2514"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "213 CALDWELL DR",
            "city": "HAZLEHURST",
            "state": "MS",
            "postal_code": "39083",
            "telephone_number": "601-894-2514",
            "fax_number": "601-894-2514"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COPIAH COUNTY MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COPIAH COUNTY MEDICAL CENTER",
        "enumeration_date": "2006-09-20",
        "last_updated": "2022-09-22",
        "certification_date": "2022-09-22",
        "status": "A",
        "authorized_official_last_name": "GADDY",
        "authorized_official_first_name": "KORTNEY",
        "authorized_official_middle_name": "M.",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "601-574-7200"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00119484",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00122024",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00011981",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00113908",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00116996",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00012939",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09013707",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00015329",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hazlehurst Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hazlehurst, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 22, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.