Provider Demographics
NPI:1275672248
Name:LOUISIANA CARDIOVASCULAR ASSOCIATES AMPC DBA LOUISIANA HEART ASSOCIATE
Entity Type:Organization
Organization Name:LOUISIANA CARDIOVASCULAR ASSOCIATES AMPC DBA LOUISIANA HEART ASSOCIATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:T
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-424-2192
Mailing Address - Street 1:1801 FAIRFIELD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4457
Mailing Address - Country:US
Mailing Address - Phone:318-424-2192
Mailing Address - Fax:318-424-2595
Practice Address - Street 1:1801 FAIRFIELD AVE STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4457
Practice Address - Country:US
Practice Address - Phone:318-424-2192
Practice Address - Fax:318-424-2595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1441414Medicaid
LACH5824OtherRRMC
LACH5824OtherRRMC
LA=========0OtherBLUECROSS