1487839783 NPI number — PEDIATRIC GROUP OF ACADIANA, LLC

Table of content: (NPI 1487839783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487839783 NPI number — PEDIATRIC GROUP OF ACADIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC GROUP OF ACADIANA, 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:
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:
1487839783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 YOUNGSVILLE HWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-5173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-330-0031
Provider Business Mailing Address Fax Number:
337-330-0059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N LEWIS ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
NEW IBERIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70563-2094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-367-2001
Provider Business Practice Location Address Fax Number:
337-365-3050
Provider Enumeration Date:
01/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GILLESPIE
Authorized Official First Name:
INGRID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
337-839-5533

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  10447R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1027537 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com