Provider Demographics
NPI:1184658361
Name:DAUTERIVE PROFESSIONALS MANAGEMENT
Entity Type:Organization
Organization Name:DAUTERIVE PROFESSIONALS MANAGEMENT
Other - Org Name:LST ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-365-2812
Mailing Address - Street 1:PO BOX 53533
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3533
Mailing Address - Country:US
Mailing Address - Phone:337-365-3168
Mailing Address - Fax:
Practice Address - Street 1:600 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2043
Practice Address - Country:US
Practice Address - Phone:337-365-3168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447030Medicaid
LADB162Medicare PIN
LA5CH84Medicare PIN