Provider Demographics
NPI:1376099010
Name:MID STATE ORTHOPAEDICS & SPORTS MEDICINE CENTER LLC
Entity Type:Organization
Organization Name:MID STATE ORTHOPAEDICS & SPORTS MEDICINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-473-9556
Mailing Address - Street 1:3444 MASONIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3615
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-484-6032
Practice Address - Street 1:5541 HWY 1
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2650
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-484-6032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID STATE ORTHOPAEDICS & SPORTS MEDICINE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1946320Medicaid
LA0570570001OtherMEDICARE DME