Provider Demographics
NPI:1346360013
Name:FAMILY MEDICAL CLINIC OF MER ROUGE
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC OF MER ROUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WYATT
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:318-647-3720
Mailing Address - Street 1:205 S DAVENPORT AVENUE
Mailing Address - Street 2:
Mailing Address - City:MER ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:71261
Mailing Address - Country:US
Mailing Address - Phone:318-647-3720
Mailing Address - Fax:318-647-5728
Practice Address - Street 1:205 SOUTH DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:MER ROUGE
Practice Address - State:LA
Practice Address - Zip Code:71261
Practice Address - Country:US
Practice Address - Phone:318-647-3720
Practice Address - Fax:318-647-5728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1949434Medicaid
LA1949434Medicaid
LA5L710Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER