Provider Demographics
NPI:1043376007
Name:PEDIATRIC MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:PEDIATRIC MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:LAMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-651-7444
Mailing Address - Street 1:501 RUE DE SANTE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-5400
Mailing Address - Country:US
Mailing Address - Phone:985-651-7444
Mailing Address - Fax:985-651-7449
Practice Address - Street 1:501 RUE DE SANTE
Practice Address - Street 2:SUITE 9
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-5400
Practice Address - Country:US
Practice Address - Phone:985-651-7444
Practice Address - Fax:985-651-7449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0152912080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449369Medicaid