Provider Demographics
NPI:1225161540
Name:BREAST SPECIALTY OF BATON ROUGE, LLC
Entity Type:Organization
Organization Name:BREAST SPECIALTY OF BATON ROUGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-216-1118
Mailing Address - Street 1:9000 AIRLINE HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-4114
Mailing Address - Country:US
Mailing Address - Phone:225-216-1118
Mailing Address - Fax:225-216-1119
Practice Address - Street 1:9000 AIRLINE HWY
Practice Address - Street 2:SUITE 250
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-4114
Practice Address - Country:US
Practice Address - Phone:225-216-1118
Practice Address - Fax:225-216-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14794R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1122866Medicaid
LA5CQ45Medicare ID - Type Unspecified
LAH87347Medicare UPIN