Provider Demographics
NPI:1508548140
Name:CARDIOVASCULAR MEDICINE OF SLIDELL, LLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR MEDICINE OF SLIDELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC
Authorized Official - Phone:504-250-6978
Mailing Address - Street 1:2965 GAUSE BLVD E
Mailing Address - Street 2:STE A
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4154
Mailing Address - Country:US
Mailing Address - Phone:985-503-7853
Mailing Address - Fax:985-263-1771
Practice Address - Street 1:2965 GAUSE BLVD E
Practice Address - Street 2:STE A
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4154
Practice Address - Country:US
Practice Address - Phone:985-503-7853
Practice Address - Fax:985-263-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-03
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1101745Medicaid