Basic Information
| Provider Information | |||||||||
| NPI: | 1760420541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HEALTHCARE AUTHORITY OF LAUDERDALE COUNTY AND THE CITY OF FLORENCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ELIZA COFFEE MEMORIAL HOSPITAL - ER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10005 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356312005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135265 | ||||||||
| FaxNumber: | 2053135245 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 MARENGO ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356306033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135265 | ||||||||
| FaxNumber: | 2053135245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MYNCK | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2567689510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE HEATHCARE AUTHORITY OF LAUDERDALE COUNTY AND THE CITY OF FLORENCE, | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | CG4578 | 01 | AL | RR MCARE GRP # | OTHER | 558200140 | 05 | AL | MEDICAID |