Provider Demographics
NPI:1003337478
Name:ORTHOPAEDIC CLINIC OF MONROE
Entity Type:Organization
Organization Name:ORTHOPAEDIC CLINIC OF MONROE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:318-362-4328
Mailing Address - Street 1:1501 LOUISVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6025
Mailing Address - Country:US
Mailing Address - Phone:318-323-8451
Mailing Address - Fax:
Practice Address - Street 1:309 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5323
Practice Address - Country:US
Practice Address - Phone:318-362-4396
Practice Address - Fax:318-361-2613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1004448Medicaid