Basic Information
| Provider Information | |||||||||
| NPI: | 1336308022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHC-OPELOUSAS LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOCTORS HOSPITAL OF OPELOUSAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3983 I 49 S SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | OPELOUSAS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705700758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379482107 | ||||||||
| FaxNumber: | 3379482173 | ||||||||
| Practice Location | |||||||||
| Address1: | 3983 I 49 S SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | OPELOUSAS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705700758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379482107 | ||||||||
| FaxNumber: | 3379482173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 09/12/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRACEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHC-OPELOUSAS LP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | COO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0202X | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207L00000X | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CH1013 | 01 | LA | RAILROAD MEDICARE | OTHER | 1706841 | 05 | LA | MEDICAID |