Provider Demographics
NPI:1043580624
Name:DESOTO HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:DESOTO HOSPITAL ASSOCIATION
Other - Org Name:DESOTO REGIONAL FAMILY MEDICINE-MANSFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-871-3101
Mailing Address - Street 1:130 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-2602
Mailing Address - Country:US
Mailing Address - Phone:318-872-2700
Mailing Address - Fax:318-872-6214
Practice Address - Street 1:130 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2602
Practice Address - Country:US
Practice Address - Phone:318-872-2700
Practice Address - Fax:318-872-6214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229RHC-3261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
193480Medicare Oscar/Certification