Provider Demographics
NPI:1285650879
Name:NEUROLOGICAL SURGERY, PMC/LLC
Entity Type:Organization
Organization Name:NEUROLOGICAL SURGERY, PMC/LLC
Other - Org Name:NEUROLOGICAL SURGERY & SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PROVENZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-2300
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-0550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2923
Practice Address - Country:US
Practice Address - Phone:985-646-2300
Practice Address - Fax:985-646-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015313207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1332402Medicaid
LA53202Medicare ID - Type UnspecifiedPROVENZA MEDICARE
LAR64751Medicare UPIN
LA1332402Medicaid
LAB64446Medicare UPIN