1578804936 NPI number — PONTCHARTRAIN ANESTHESIA, LLC

Table of content: (NPI 1578804936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578804936 NPI number — PONTCHARTRAIN ANESTHESIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONTCHARTRAIN ANESTHESIA, 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:
1578804936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75024 EMERYWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABITA SPRINGS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70420-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-231-3957
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2781 CT SWITZER SR DR
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-388-4585
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FOURCADE
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING/BILLING MANAGER
Authorized Official Telephone Number:
985-781-8565

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2354779 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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