Provider Demographics
NPI:1376253138
Name:BLUEFIN MEDICAL, LLC
Entity Type:Organization
Organization Name:BLUEFIN MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-773-5880
Mailing Address - Street 1:850 MARGARET PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4521
Mailing Address - Country:US
Mailing Address - Phone:318-208-2000
Mailing Address - Fax:
Practice Address - Street 1:850 MARGARET PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4521
Practice Address - Country:US
Practice Address - Phone:318-208-2000
Practice Address - Fax:318-227-7627
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE MEDICAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486647Medicaid