Provider Demographics
NPI:1558491803
Name:LAKE CHARLES MEDICAL SERVICES UROLOGY LLC
Entity Type:Organization
Organization Name:LAKE CHARLES MEDICAL SERVICES UROLOGY LLC
Other - Org Name:UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-HATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-494-2094
Mailing Address - Street 1:PO BOX 122525 DEPT 2525
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2525
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 240
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8994
Practice Address - Country:US
Practice Address - Phone:337-494-4656
Practice Address - Fax:337-494-4657
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE CHARLES MEDICAL SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1030562Medicaid
LANH6217OtherBCBS
LA0700010826OtherOCCUPATIONAL LICENSE
LA1030562Medicaid