1053589697 NPI number — BIENVILLE MEDICAL CENTER PHYSICIAN GROUP

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 1053589697 NPI number — BIENVILLE MEDICAL CENTER PHYSICIAN GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIENVILLE MEDICAL CENTER PHYSICIAN GROUP
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:
1053589697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1175 PINE ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71001-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1175 PINE ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71001-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-629-5340
Provider Business Practice Location Address Fax Number:
318-221-8205
Provider Enumeration Date:
02/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BORDELON
Authorized Official First Name:
ROCK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
318-221-3202

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1707023 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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