Provider Demographics
NPI:1003135633
Name:CHARLIE H BRIDGES MD, FACS
Entity Type:Organization
Organization Name:CHARLIE H BRIDGES MD, FACS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-767-0394
Mailing Address - Street 1:7777 HENNESSY BLVD STE 608
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4366
Mailing Address - Country:US
Mailing Address - Phone:225-767-0394
Mailing Address - Fax:225-767-3904
Practice Address - Street 1:7777 HENNESSY BLVD STE 608
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4366
Practice Address - Country:US
Practice Address - Phone:225-767-0394
Practice Address - Fax:225-767-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07141R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1370339Medicaid
LA1370339Medicaid
LA53664Medicare PIN