Provider Demographics
NPI:1487839783
Name:PEDIATRIC GROUP OF ACADIANA, LLC
Entity Type:Organization
Organization Name:PEDIATRIC GROUP OF ACADIANA, LLC
Other - Org Name:NEW IBERIA MATERNAL CHILD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MISS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:R
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:337-839-5533
Mailing Address - Street 1:401 YOUNGSVILLE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5173
Mailing Address - Country:US
Mailing Address - Phone:337-330-0031
Mailing Address - Fax:337-330-0059
Practice Address - Street 1:520 N LEWIS ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2094
Practice Address - Country:US
Practice Address - Phone:337-367-2001
Practice Address - Fax:337-365-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10447R174400000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1027537Medicaid
LA193884Medicare Oscar/Certification