Basic Information
| Provider Information | |||||||||
| NPI: | 1801069885 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHCARE AUTHORITY OF MORGAN COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DECATUR GENERAL HOSPITAL PEC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1201 7TH ST SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356013337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563412010 | ||||||||
| FaxNumber: | 2563061691 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 7TH ST SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356013337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563412010 | ||||||||
| FaxNumber: | 2563061691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PFS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2563412010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTHCARE AUTHORITY OF MORGAN COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | H5202 | AL | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | PEC00085H | 05 | AL | MEDICAID |