1629105416 NPI number — PEDIATRIC HEALTH ASSOCIATES, L.L.C.

Table of content: (NPI 1629105416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629105416 NPI number — PEDIATRIC HEALTH ASSOCIATES, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC HEALTH ASSOCIATES, L.L.C.
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:
1629105416
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:
624 CHEVELLE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70806-6502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-925-2055
Provider Business Mailing Address Fax Number:
225-925-2142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 CHEVELLE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-6502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-925-2055
Provider Business Practice Location Address Fax Number:
225-925-2142
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEDGEMON
Authorized Official First Name:
HELEN
Authorized Official Middle Name:
KAYE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
225-925-2055

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  06831R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LF0000X , with the licence number: RN032514 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 1689664104 . This is a "INDIVIDUAL NPI FOR NP" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1449245 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487681359 . This is a "INDIVIDUAL NPI FOR DR" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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