Basic Information
Provider Information | |||||||||
NPI: | 1043361959 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMEDISYS MISSOURI, L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMEDISYS HOME HEALTH OF MISSOURI | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 1027 S MAIN ST | ||||||||
Address2: | SUITE 6 | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648014527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4172066500 | ||||||||
FaxNumber: | 4172064003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 12/16/2016 | ||||||||
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 | 780 | MO | N |   | Agencies | Home Health |   | 251E00000X | 783-6HH | MO | N |   | Agencies | Home Health |   | 251E00000X | 783-7HH | MO | N |   | Agencies | Home Health |   | 251E00000X | 783-9HH | MO | N |   | Agencies | Home Health |   | 251E00000X | 885-10HH | MO | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 586304305 | 05 | MO |   | MEDICAID |