Provider Demographics
NPI:1225161706
Name:CHILDRENS MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:CHILDRENS MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROSELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ST ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-582-9922
Mailing Address - Street 1:4701 WESTBANK EXPY STE 7
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3050
Mailing Address - Country:US
Mailing Address - Phone:504-582-9922
Mailing Address - Fax:504-582-9928
Practice Address - Street 1:4701 WESTBANK EXPY STE 7
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3050
Practice Address - Country:US
Practice Address - Phone:504-582-9922
Practice Address - Fax:504-582-9928
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S MEDICAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-13
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1446319Medicaid
LA1564362Medicaid