Provider Demographics
NPI:1205385796
Name:MID STATE ORTHOPAEDIC & SPORTS MEDICINE CENTER LLC
Entity Type:Organization
Organization Name:MID STATE ORTHOPAEDIC & SPORTS MEDICINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-473-9556
Mailing Address - Street 1:3444 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3615
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-484-6032
Practice Address - Street 1:601 W LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3451
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-484-6032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDSTATE ORTHOPAEDIC & SPORTS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9317843207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACD7720OtherRAILROAD MEDICARE
LA1946320Medicaid
LA0570570001Medicare NSC