Provider Demographics
NPI:1457489593
Name:DESOTO HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:DESOTO HOSPITAL ASSOCIATION
Other - Org Name:DESOTO REGINAL FAMILY MEDICINE - LOGANSPORT
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 1:808 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71049
Mailing Address - Country:US
Mailing Address - Phone:318-697-2273
Mailing Address - Fax:318-697-2277
Practice Address - Street 1:808 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:LA
Practice Address - Zip Code:71049
Practice Address - Country:US
Practice Address - Phone:318-697-2273
Practice Address - Fax:318-697-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445932Medicaid
LA5C630OtherMDEICARE
LA193448OtherMEDICARE
LA193449Medicare PIN