Basic Information
| Provider Information | |||||||||
| NPI: | 1649471251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE HEALTH CARE AUTHORITY OF LAUDERDALE COUNTY AND THE CITY OF FLORENC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHOALS HOSPTIAL-CRNA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10005 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356312005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567689191 | ||||||||
| FaxNumber: | 2567689775 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 AVALON AVE | ||||||||
| Address2: | |||||||||
| City: | MUSCLE SHOALS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356612805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567689191 | ||||||||
| FaxNumber: | 2567689775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITT | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
| AuthorizedOfficialMiddleName: | LEWIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2567689191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE HEALTH CARE AUTHORITY OF LAUDERDALE COUNTY AND THE CITY OF FLORENC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | H1702 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 529904540 | 05 | AL | MEDICAID |