Basic Information
| Provider Information | |||||||||
| NPI: | 1770524597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | W O MOSS REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 WALTERS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374758100 | ||||||||
| FaxNumber: | 3374758104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WALTERS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706074647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374758100 | ||||||||
| FaxNumber: | 3374758104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITHBURG | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE CHANCELLOR CEO | ||||||||
| AuthorizedOfficialTelephone: | 2259221474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | X | Hospitals | General Acute Care Hospital | 363A00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1799165 | 05 | LA | MEDICAID | 1449415 | 05 | LA | MEDICAID |