Provider Demographics
NPI:1538113717
Name:PEDIATRIC NEUROLOGY OF ACADIANA
Entity Type:Organization
Organization Name:PEDIATRIC NEUROLOGY OF ACADIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:KEVILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-993-7391
Mailing Address - Street 1:4540 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:#B130
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6928
Mailing Address - Country:US
Mailing Address - Phone:337-993-7391
Mailing Address - Fax:337-993-7394
Practice Address - Street 1:4540 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:#B130
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6928
Practice Address - Country:US
Practice Address - Phone:337-993-7391
Practice Address - Fax:337-993-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1943215Medicaid
LA5CG53Medicare ID - Type Unspecified