Basic Information
| Provider Information | |||||||||
| NPI: | 1396938015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMEDISYS HOSPICE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMEDISYS HOSPICE CARE OF KENNESAW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3854 AMERICAN WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252922031 | ||||||||
| FaxNumber: | 2252959678 | ||||||||
| Practice Location | |||||||||
| Address1: | 4255 WADE GREEN RD NW BLDG 300 | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301441762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704231316 | ||||||||
| FaxNumber: | 7704267453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | KUSSEROW | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252922031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 538644165A | 05 | GA | MEDICAID |