Provider Demographics
NPI:1477700656
Name:IBERIA BONE JOINT & FOOT CLINIC AMC
Entity Type:Organization
Organization Name:IBERIA BONE JOINT & FOOT CLINIC AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-454-6000
Mailing Address - Street 1:7855 HOWELL BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-5257
Mailing Address - Country:US
Mailing Address - Phone:225-454-6000
Mailing Address - Fax:225-302-7255
Practice Address - Street 1:7855 HOWELL BLVD
Practice Address - Street 2:STE 200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-5257
Practice Address - Country:US
Practice Address - Phone:225-454-6000
Practice Address - Fax:225-302-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021167174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1907600Medicaid