Provider Demographics
NPI:1407281546
Name:COMMUNITY MEDICAL GROUP-ST CHARLES INC
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL GROUP-ST CHARLES INC
Other - Org Name:COMMUNITY MEDICAL GROUP-ST CHARLES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-522-2014
Mailing Address - Street 1:503 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5327
Mailing Address - Country:US
Mailing Address - Phone:318-329-4700
Mailing Address - Fax:
Practice Address - Street 1:1057 PAUL MAILLARD RD
Practice Address - Street 2:SUITE2250
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4349
Practice Address - Country:US
Practice Address - Phone:985-785-2218
Practice Address - Fax:985-785-7753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2351036Medicaid
LA317531Medicare PIN