Basic Information
| Provider Information | |||||||||
| NPI: | 1942203476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMH PROFESSIONAL SERV AT SMH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 INNWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704339123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858923225 | ||||||||
| FaxNumber: | 9852340628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 GAUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704582939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856432200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2005 | ||||||||
| LastUpdateDate: | 09/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9856498866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1442755 | 05 | LA | MEDICAID | 09016024 | 05 | MS | MEDICAID |