Provider Demographics
NPI:1255659363
Name:DR. KEITH CALHOUN, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DR. KEITH CALHOUN, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CALHOUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-324-1414
Mailing Address - Street 1:4400 OLD STERLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2396
Mailing Address - Country:US
Mailing Address - Phone:318-324-1414
Mailing Address - Fax:318-324-2120
Practice Address - Street 1:4400 OLD STERLINGTON RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2396
Practice Address - Country:US
Practice Address - Phone:318-324-1414
Practice Address - Fax:318-324-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024133173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1571121Medicaid
LA1780697227Medicare PIN
5H872Medicare UPIN
LA5DN15Medicare UPIN
LA1571121Medicaid