1457489593 NPI number — DESOTO HOSPITAL ASSOCIATION

Table of content: (NPI 1457489593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457489593 NPI number — DESOTO HOSPITAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESOTO HOSPITAL ASSOCIATION
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:
DESOTO REGINAL FAMILY MEDICINE - LOGANSPORT
Provider Other Organization Name Type Code:
3
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:
1457489593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANSPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-697-2273
Provider Business Mailing Address Fax Number:
318-697-2277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-697-2273
Provider Business Practice Location Address Fax Number:
318-697-2277
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEUTSCH
Authorized Official First Name:
HALLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
318-871-3101

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1445932 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5C630 . This is a "MDEICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 193448 . This is a "MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com