Basic Information
| Provider Information | |||||||||
| NPI: | 1023068459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHWEST ALABAMA HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 415 | ||||||||
| Address2: | 7777 HWY 43 NORTH | ||||||||
| City: | MC INTOSH | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365530415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519442842 | ||||||||
| FaxNumber: | 2519448070 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HIGHWAY 43 NORTH | ||||||||
| Address2: | |||||||||
| City: | MCINTOSH | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365530415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519442842 | ||||||||
| FaxNumber: | 2519448070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2518242174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | PHL L6503 | AL | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 630002015 | 05 | AL | MEDICAID | 01DO692409 | 01 | AL | CLIA | OTHER | 630000015 | 05 | AL | MEDICAID |