Provider Demographics
NPI:1326210824
Name:C W KRIEGER JR A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:C W KRIEGER JR A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:KRIEGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-3664
Mailing Address - Street 1:PO BOX 1819
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-1819
Mailing Address - Country:US
Mailing Address - Phone:985-646-3664
Mailing Address - Fax:985-646-3683
Practice Address - Street 1:1150 ROBERT BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2004
Practice Address - Country:US
Practice Address - Phone:985-646-3664
Practice Address - Fax:985-646-3683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010738207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0494960001Medicare NSC
LAB64442Medicare UPIN