Provider Demographics
NPI:1164686689
Name:STANLEY R KORDISCH M D AMC
Entity Type:Organization
Organization Name:STANLEY R KORDISCH M D AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CULPEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-474-0653
Mailing Address - Street 1:4150 NELSON RD STE C10
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4169
Mailing Address - Country:US
Mailing Address - Phone:337-474-0653
Mailing Address - Fax:337-474-0639
Practice Address - Street 1:4150 NELSON RD STE C10
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4169
Practice Address - Country:US
Practice Address - Phone:337-474-0653
Practice Address - Fax:337-474-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB89596Medicare UPIN