1245288943 NPI number — AMEDISYS MISSISSIPPI, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245288943 NPI number — AMEDISYS MISSISSIPPI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMEDISYS MISSISSIPPI, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245288943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3854 AMERICAN WAY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-292-2031
Provider Business Mailing Address Fax Number:
225-295-9678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2080 S FRONTAGE RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39180-5328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-619-3670
Provider Business Practice Location Address Fax Number:
601-619-3672
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUSSEROW
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
225-292-2031

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  7394 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00770548 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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