Basic Information
| Provider Information | |||||||||
| NPI: | 1366617367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST COMMUNITY HEALTH SYSTEMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHEAST COMMUNITY HEALTH SYSTEMS @ ALBANY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 770 | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707910770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253062000 | ||||||||
| FaxNumber: | 2256581282 | ||||||||
| Practice Location | |||||||||
| Address1: | 30575 OLD BATON ROUGE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253062050 | ||||||||
| FaxNumber: | 2255676962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | CYPRIAN | ||||||||
| AuthorizedOfficialFirstName: | ALECIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2253062000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1061115 | 05 | LA | MEDICAID |