Provider Demographics
NPI:1083610364
Name:IMAGING CENTER OF SOUTH LOUISIANA, LLC
Entity Type:Organization
Organization Name:IMAGING CENTER OF SOUTH LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:SEVERINUS
Authorized Official - Last Name:GERVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-850-6805
Mailing Address - Street 1:P.O. BOX 1047
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:LA
Mailing Address - Zip Code:70359
Mailing Address - Country:US
Mailing Address - Phone:985-580-2888
Mailing Address - Fax:985-851-2786
Practice Address - Street 1:114 NEUROSCIENCE COURT
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359
Practice Address - Country:US
Practice Address - Phone:985-580-2888
Practice Address - Fax:985-851-7526
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST NEUROSCIENCE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-22
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1443212Medicaid
LA470001531Medicare PIN
LA1443212Medicaid