Provider Demographics
NPI:1598212490
Name:FREEDOM HOSPITAL OF MAGNOLIA LLC
Entity Type:Organization
Organization Name:FREEDOM HOSPITAL OF MAGNOLIA LLC
Other - Org Name:BEACHAM MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-802-1336
Mailing Address - Street 1:4815 IHLES RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5900
Mailing Address - Country:US
Mailing Address - Phone:337-802-1336
Mailing Address - Fax:
Practice Address - Street 1:205 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2819
Practice Address - Country:US
Practice Address - Phone:601-783-2353
Practice Address - Fax:601-783-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS20043Medicaid
25U049Medicare PIN
25S049Medicare PIN
250049Medicare PIN