Basic Information
Provider Information | |||||||||
NPI: | 1063719599 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKELAND COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAKELAND COMMUNITY HOSPITAL PSYCHIATRIC UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 42024 HIGHWAY 195 | ||||||||
Address2: | P.O. BOX 780 | ||||||||
City: | HALEYVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 35565 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2054865213 | ||||||||
FaxNumber: | 2054857127 | ||||||||
Practice Location | |||||||||
Address1: | 42024 HWY 195 | ||||||||
Address2: |   | ||||||||
City: | HALEYVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 355657054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2054857108 | ||||||||
FaxNumber: | 2054857127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2011 | ||||||||
LastUpdateDate: | 08/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUKHERJI | ||||||||
AuthorizedOfficialFirstName: | ASHOKE 'BAPPA' | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | JAVA MEDICAL GROUP CEO | ||||||||
AuthorizedOfficialTelephone: | 6153088800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X |   |   | N |   | Hospital Units | Psychiatric Unit |   | 364SG0600X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
No ID Information.