Provider Demographics
NPI:1558340083
Name:SOUTHERN MEDICAL HOLDING CORPORATION
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL HOLDING CORPORATION
Other - Org Name:SOUTHERN MEDICAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, MBA
Authorized Official - Phone:225-756-5239
Mailing Address - Street 1:12133 INDUSTRIPLEX BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-5129
Mailing Address - Country:US
Mailing Address - Phone:225-756-5239
Mailing Address - Fax:225-752-2614
Practice Address - Street 1:12133 INDUSTRIPLEX BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-5129
Practice Address - Country:US
Practice Address - Phone:225-756-5239
Practice Address - Fax:225-752-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA170011032246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1121894Medicaid
MO506047901Medicaid
LAC3563OtherBLUE CROSS PROV.NUMBER
MO001013514Medicare ID - Type UnspecifiedPROVIDER NUMBER
LA1121894Medicaid
MO506047901Medicaid
LA5C440Medicare ID - Type UnspecifiedPROVIDER NUMBER