Basic Information
| Provider Information | |||||||||
| NPI: | 1336346451 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCHSNER MEDICAL CENTER - HANCOCK LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OCHSNER HEALTH CENTER - PORT BIENVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 149 DRINKWATER RD | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395201658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678744 | ||||||||
| FaxNumber: | 2284678799 | ||||||||
| Practice Location | |||||||||
| Address1: | 3068 PORT AND HARBOR DR | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285339000 | ||||||||
| FaxNumber: | 2284678799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2284678744 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OCHSNER MEDICAL CENTER - HANCOCK LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 11214 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 09015655 | 05 | MS | MEDICAID |