Provider Demographics
NPI:1548207772
Name:W O MOSS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:W O MOSS REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-922-0775
Mailing Address - Street 1:1000 WALTERS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4647
Mailing Address - Country:US
Mailing Address - Phone:337-475-8100
Mailing Address - Fax:337-475-8104
Practice Address - Street 1:1000 WALTERS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4647
Practice Address - Country:US
Practice Address - Phone:337-475-8100
Practice Address - Fax:337-475-8104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:W O MOSS REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-31
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1705225Medicaid
LA60979OtherPSYCH
LA19S161Medicare Oscar/Certification