Provider Demographics
NPI:1790115756
Name:ASERACARE HOSPICE - JACKSON LLC
Entity Type:Organization
Organization Name:ASERACARE HOSPICE - JACKSON LLC
Other - Org Name:PRIME BY ASERACARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSSEROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-292-2031
Mailing Address - Street 1:3854 AMERICAN WAY STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4897
Mailing Address - Country:US
Mailing Address - Phone:225-292-2031
Mailing Address - Fax:225-295-9678
Practice Address - Street 1:1201 MONTLIMAR DR
Practice Address - Street 2:STE 100
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1704
Practice Address - Country:US
Practice Address - Phone:251-343-0989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G707532Medicare Oscar/Certification