Basic Information
Provider Information | |||||||||
NPI: | 1326288770 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DECATUR GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE HEALTHCARE AUTHORITY OF MORGAN COUNTY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2239 | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356092239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563412000 | ||||||||
FaxNumber: | 2563061691 | ||||||||
Practice Location | |||||||||
Address1: | 2205 BELTLINE RD SW | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356013617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563412010 | ||||||||
FaxNumber: | 2563061691 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/25/2009 | ||||||||
LastUpdateDate: | 04/29/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BONETTI | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXE DIR, REVENUE CYC | ||||||||
AuthorizedOfficialTelephone: | 2562659641 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 11859 | AL | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 010-824 | 01 | AL | BLUE CROSS | OTHER | HOS0085H | 05 | AL |   | MEDICAID |