Basic Information
| Provider Information | |||||||||
| NPI: | 1831676485 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SYLACAUGA HEALTH CARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CVMC ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014534 | ||||||||
| FaxNumber: | 2564014603 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014534 | ||||||||
| FaxNumber: | 2564014603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2018 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THACKER | ||||||||
| AuthorizedOfficialFirstName: | ROLAND | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2564014534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SYLACAUGA HEALTH CARE AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | H6102 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | H6102 | 01 | AL | HOSPITAL LICENSE | OTHER | HOS0164H | 05 | AL | MEDICAID |