Basic Information
Provider Information | |||||||||
NPI: | 1942441084 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKWALL BATON ROUGE REHAB HOSPITAL LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAGE REHABILITATION HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8000 SUMMA AVENUE | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 70809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2258190703 | ||||||||
FaxNumber: | 2259064085 | ||||||||
Practice Location | |||||||||
Address1: | 8000 SUMMA AVENUE | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 70809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2258190703 | ||||||||
FaxNumber: | 2259064085 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2009 | ||||||||
LastUpdateDate: | 09/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IVY | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2259064884 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 653 | LA | Y |   | Hospitals | Rehabilitation Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 1700576 | 05 | LA |   | MEDICAID |