Provider Demographics
NPI:1316188998
Name:PHYSICIAN GROUP OF LOUISIANA INC
Entity Type:Organization
Organization Name:PHYSICIAN GROUP OF LOUISIANA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-7070
Mailing Address - Street 1:PO BOX 281796
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1796
Mailing Address - Country:US
Mailing Address - Phone:866-243-7107
Mailing Address - Fax:314-432-9683
Practice Address - Street 1:503 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5327
Practice Address - Country:US
Practice Address - Phone:318-329-4200
Practice Address - Fax:318-329-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1818593Medicaid
LA1818593Medicaid