Provider Demographics
NPI:1003904236
Name:PEDIATRIC CLINIC WESTBANK
Entity Type:Organization
Organization Name:PEDIATRIC CLINIC WESTBANK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-392-9298
Mailing Address - Street 1:151 MEADOWCREST ST STE F
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-5256
Mailing Address - Country:US
Mailing Address - Phone:504-392-9298
Mailing Address - Fax:504-392-7047
Practice Address - Street 1:151 MEADOWCREST ST STE F
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5256
Practice Address - Country:US
Practice Address - Phone:504-392-9298
Practice Address - Fax:504-392-7047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018557208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1945242Medicaid