1780879015 NPI number — JOSE E MERCED MD LLC

Table of content: (NPI 1780879015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780879015 NPI number — JOSE E MERCED MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSE E MERCED MD 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:
1780879015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 81023
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70598-1023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-769-3002
Provider Business Mailing Address Fax Number:
337-769-0309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 LA NEUVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70592-5212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-769-3002
Provider Business Practice Location Address Fax Number:
337-769-0309
Provider Enumeration Date:
09/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MERCED
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
EDGARDO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
337-769-3002

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  021815 , 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: 1982491 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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