Provider Demographics
NPI:1508850413
Name:WEST JEFFERSON SURGERY CENTER LLC
Entity Type:Organization
Organization Name:WEST JEFFERSON SURGERY CENTER LLC
Other - Org Name:GWEN MCINNIS ADMINISTRATOR
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:MORVANT
Authorized Official - Last Name:MCINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN MHA
Authorized Official - Phone:504-349-6017
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE 105 NORTH
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-349-2332
Mailing Address - Fax:504-349-2359
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 105 NORTH
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-2332
Practice Address - Fax:504-349-2359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
115OtherLIC
A50004330OtherSTATE
LA1150011Medicaid
LA1150011Medicaid