Basic Information
Provider Information | |||||||||
NPI: | 1083651525 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASERACARE HOSPICE - RUSSELLVILLE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASERACARE HOSPICE - DECATUR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3854 AMERICAN WAY STE A | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708164897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2252922031 | ||||||||
FaxNumber: | 2252959678 | ||||||||
Practice Location | |||||||||
Address1: | 432 MOULTON ST E | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356013002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3307602805 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 07/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KUSSEROW | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2252922031 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X |   |   | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | PIC1028E | 05 | AL |   | MEDICAID | 012-491 | 01 |   | BCBS | OTHER |