Basic Information
Provider Information | |||||||||
NPI: | 1871507616 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPRINGHILL MEDICAL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SMC DOCTORS CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 11TH ST NE | ||||||||
Address2: |   | ||||||||
City: | SPRINGHILL | ||||||||
State: | LA | ||||||||
PostalCode: | 710754503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3185391700 | ||||||||
FaxNumber: | 3185395688 | ||||||||
Practice Location | |||||||||
Address1: | 401 11TH ST NE | ||||||||
Address2: |   | ||||||||
City: | SPRINGHILL | ||||||||
State: | LA | ||||||||
PostalCode: | 710754503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3185391700 | ||||||||
FaxNumber: | 3185395688 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 05/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATRONIS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3185391001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SPRINGHILL MEDICAL SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 105 | LA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 160435729 | 05 | AR |   | MEDICAID | 1448290 | 05 | LA |   | MEDICAID | 1441601 | 05 | LA |   | MEDICAID |