Provider Demographics
NPI:1477734424
Name:CARDIOVASCULAR INSTITUTE OF THE SOUTH, APMC
Entity Type:Organization
Organization Name:CARDIOVASCULAR INSTITUTE OF THE SOUTH, APMC
Other - Org Name:FAMILY DOCTORS CLINIC OF MATHEWS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:KONUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-876-0300
Mailing Address - Street 1:225 DUNN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4413
Mailing Address - Country:US
Mailing Address - Phone:985-873-5669
Mailing Address - Fax:985-872-0317
Practice Address - Street 1:111 ACADIA PARK DR
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-2619
Practice Address - Country:US
Practice Address - Phone:985-537-7575
Practice Address - Fax:985-537-7584
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDIOVASCULAR INSTITUTE OF THE SOUTH, APMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447943Medicaid
LA4135970001Medicare NSC