Basic Information
| Provider Information | |||||||||
| NPI: | 1790744506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABBEVILLE GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ABBEVILLE GENERAL HOSPITAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 N HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705104039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378935466 | ||||||||
| FaxNumber: | 3378932801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2419 ALONZO ST | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705104008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378920630 | ||||||||
| FaxNumber: | 3378930403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANDRY | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3378935466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 160 RHC-1 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1448087 | 05 | LA | MEDICAID |