Provider Demographics
NPI:1891013496
Name:MOREHOUSE PARISH HOSPITAL SERVICE DISTRICT 1
Entity Type:Organization
Organization Name:MOREHOUSE PARISH HOSPITAL SERVICE DISTRICT 1
Other - Org Name:MGH PHYSICIANS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-283-3601
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0293
Mailing Address - Country:US
Mailing Address - Phone:318-283-3622
Mailing Address - Fax:318-239-8622
Practice Address - Street 1:425 S VINE ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4513
Practice Address - Country:US
Practice Address - Phone:318-283-3960
Practice Address - Fax:318-239-8960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOREHOUSE GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-07
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2114646Medicaid
LA2114646Medicaid