Basic Information
| Provider Information | |||||||||
| NPI: | 1003032475 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMEDISYS GEORGIA LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3854 AMERICAN WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252922031 | ||||||||
| FaxNumber: | 2252959678 | ||||||||
| Practice Location | |||||||||
| Address1: | 691 441 HISTORIC HWY N | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | DEMOREST | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305354569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664649124 | ||||||||
| FaxNumber: | 8662683586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUSSEROW | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252922031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 055-240 | GA | N | Agencies | Home Health | 251E00000X | 059-240-H | GA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 00824909C | 05 | GA | MEDICAID |