Provider Demographics
NPI:1164558490
Name:PACE GREATER NEW ORLEANS
Entity Type:Organization
Organization Name:PACE GREATER NEW ORLEANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:WADGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-596-3099
Mailing Address - Street 1:4201 N RAMPART ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70117-5334
Mailing Address - Country:US
Mailing Address - Phone:504-945-1531
Mailing Address - Fax:
Practice Address - Street 1:4201 N RAMPART ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70117-5334
Practice Address - Country:US
Practice Address - Phone:504-945-1531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1714470Medicaid