Basic Information
| Provider Information | |||||||||
| NPI: | 1417098054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DECATUR GENERAL HOSPITAL | ||||||||
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| OtherOrganizationName: | DECATUR CARDIOVASCULAR SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 SOMERVILLE RD SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356013242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563504902 | ||||||||
| FaxNumber: | 2563504984 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 SOMERVILLE RD SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356013242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563504902 | ||||||||
| FaxNumber: | 2563504984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 08/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | HAHN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2563412000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DECATUR GENERAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | C879 | 01 | AL | BCBS | OTHER |