1508850413 NPI number — WEST JEFFERSON SURGERY CENTER LLC

Table of content: (NPI 1508850413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508850413 NPI number — WEST JEFFERSON SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST JEFFERSON SURGERY CENTER 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:
GWEN MCINNIS ADMINISTRATOR
Provider Other Organization Name Type Code:
4
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:
1508850413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 MEDICAL CENTER BLVD
Provider Second Line Business Mailing Address:
STE 105 NORTH
Provider Business Mailing Address City Name:
MARRERO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-349-2332
Provider Business Mailing Address Fax Number:
504-349-2359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
STE 105 NORTH
Provider Business Practice Location Address City Name:
MARRERO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-349-2332
Provider Business Practice Location Address Fax Number:
504-349-2359
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCINNIS
Authorized Official First Name:
GWENDOLYN
Authorized Official Middle Name:
MORVANT
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
504-349-6017

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115 . This is a "LIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: A50004330 . This is a "STATE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1150011 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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