1942393699 NPI number — BLUEBONNET IMAGING CENTER, LLC

Table of content: (NPI 1942393699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942393699 NPI number — BLUEBONNET IMAGING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEBONNET IMAGING CENTER, 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:
1942393699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4241 VETERANS MEMORIAL BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70006-5430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-459-3220
Provider Business Mailing Address Fax Number:
504-883-5384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4570 BLUEBONNET BLVD.
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-298-3223
Provider Business Practice Location Address Fax Number:
225-298-5474
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STAGG
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
225-270-7077

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1025666 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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