Basic Information
Provider Information | |||||||||
NPI: | 1730380346 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE HEALTH CARE AUTHORITY OF LAUDERDALE COUNTY AND THE CITY OF FLORENC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SHOALS HOSPITAL-HOSPITALIST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIGG | ||||||||
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: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | H1702 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 529904540 | 05 | AL |   | MEDICAID |