Provider Demographics
NPI:1083662746
Name:NORTHLAKE RADIOLOGY CONSULTANTS, APMC
Entity Type:Organization
Organization Name:NORTHLAKE RADIOLOGY CONSULTANTS, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KLAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROVIRA
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-0691
Mailing Address - Street 1:PO BOX 2710
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-2710
Mailing Address - Country:US
Mailing Address - Phone:985-646-0691
Mailing Address - Fax:985-646-0750
Practice Address - Street 1:1001 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2939
Practice Address - Country:US
Practice Address - Phone:985-649-8545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05974773Medicaid
MS09012709Medicaid
MS08927838Medicaid
=========002OtherCHAMPUS
LA=========0OtherBLUE CROSS
=========003OtherCHAMPUS
MS09012709Medicaid
=========004OtherCHAMPUS
=========003OtherCHAMPUS
LA=========0OtherBLUE CROSS
LA56681Medicare ID - Type Unspecified
MS08927838Medicaid