1164683645 NPI number — MCKENNA GENERAL MEDICAL, LLC

Table of content: (NPI 1164683645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164683645 NPI number — MCKENNA GENERAL MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCKENNA GENERAL MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164683645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1827 GENTILLY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70119-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-943-1923
Provider Business Mailing Address Fax Number:
504-943-1933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1827 GENTILLY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70119-2051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-943-1923
Provider Business Practice Location Address Fax Number:
504-943-1933
Provider Enumeration Date:
06/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCKENNA
Authorized Official First Name:
DWIGHT
Authorized Official Middle Name:
LAWRENCE
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
504-943-1923

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1129267 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: UP4206 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: F4229 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 436664206B . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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