1518100312 NPI number — CRESCENT CITY DERMATOLOGY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518100312 NPI number — CRESCENT CITY DERMATOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESCENT CITY DERMATOLOGY, 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:
1518100312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 S PETERS ST
Provider Second Line Business Mailing Address:
UNIT 404
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70130-1759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-937-0319
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 MEADOWCREST ST
Provider Second Line Business Practice Location Address:
SUITE 460
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70056-5255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-937-0319
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KLINGER
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PART OWNER
Authorized Official Telephone Number:
614-937-0319

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  200999 , 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: 1216887 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356531677 . This is a "NPI NUMBER" identifier . This identifiers is of the category "OTHER".




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