Provider Demographics
NPI:1093776429
Name:BUNDRICK AND O'NEAL PLASTIC SURGERY (AMC)
Entity Type:Organization
Organization Name:BUNDRICK AND O'NEAL PLASTIC SURGERY (AMC)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-221-9671
Mailing Address - Street 1:2210 LINE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2152
Mailing Address - Country:US
Mailing Address - Phone:318-221-9671
Mailing Address - Fax:318-425-2343
Practice Address - Street 1:2210 LINE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2152
Practice Address - Country:US
Practice Address - Phone:318-221-9671
Practice Address - Fax:318-425-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1798908Medicaid
LA5B255Medicare ID - Type Unspecified