Basic Information
| Provider Information | |||||||||
| NPI: | 1023147113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST COMMUNITY HEALTH SYSTEMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHEAST COMMUNITY HEALTH SYSTEMS @ GREENSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | POST OFFICE BOX 770 | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252226059 | ||||||||
| FaxNumber: | 8883349386 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 SITMAN STREET | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252226059 | ||||||||
| FaxNumber: | 2252226543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | CYPRIAN | ||||||||
| AuthorizedOfficialFirstName: | ALECIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2253062010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1943207 | 05 | LA | MEDICAID |