Provider Demographics
NPI:1356512107
Name:LIBBY ELLENT MD INTERNAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:LIBBY ELLENT MD INTERNAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-349-6390
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE N308
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-6390
Mailing Address - Fax:504-349-6391
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE N308
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6390
Practice Address - Fax:504-349-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12226R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CG40Medicare PIN