Provider Demographics
NPI:1558573097
Name:LA PLACE DERMATOLOGY CLINIC A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:LA PLACE DERMATOLOGY CLINIC A PROFESSIONAL MEDICAL CORP
Other - Org Name:LAPLACE DERMATOLOGY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:P
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-652-7191
Mailing Address - Street 1:398 BELLE TERRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAPLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068
Mailing Address - Country:US
Mailing Address - Phone:985-652-7191
Mailing Address - Fax:
Practice Address - Street 1:398 BELLE TERRE BLVD
Practice Address - Street 2:
Practice Address - City:LAPLACE
Practice Address - State:LA
Practice Address - Zip Code:70068
Practice Address - Country:US
Practice Address - Phone:985-652-7191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0-10905207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1145351Medicaid
LA57517Medicare ID - Type Unspecified
LAB65599Medicare UPIN