1174624712 NPI number — JON V. SCHELLACK, M.D. (A PROFESSIONAL MEDICAL CORPORATION)

Table of content: (NPI 1174624712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174624712 NPI number — JON V. SCHELLACK, M.D. (A PROFESSIONAL MEDICAL CORPORATION)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JON V. SCHELLACK, M.D. (A PROFESSIONAL MEDICAL CORPORATION)
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:
6
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:
1174624712
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:
5425 BRITTANY DR # B
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:
70808-9144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-767-5479
Provider Business Mailing Address Fax Number:
225-767-5147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5425 BRITTANY DR # B
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:
70808-9144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-767-5479
Provider Business Practice Location Address Fax Number:
225-767-5147
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHELLACK
Authorized Official First Name:
JON
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
225-767-5479

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1446564 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com