1558491803 NPI number — LAKE CHARLES MEDICAL SERVICES UROLOGY LLC

Table of content: (NPI 1558491803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558491803 NPI number — LAKE CHARLES MEDICAL SERVICES UROLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE CHARLES MEDICAL SERVICES UROLOGY 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:
1558491803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 122525 DEPT 2525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75312-2525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-494-2921
Provider Business Mailing Address Fax Number:
337-494-6523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2770 3RD AVE STE 240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-8994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-494-4656
Provider Business Practice Location Address Fax Number:
337-494-4657
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON-HATCHER
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
337-494-2094

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1030562 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NH6217 . This is a "BCBS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 0700010826 . This is a "OCCUPATIONAL LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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