Provider Demographics
NPI:1558760785
Name:EDDIE SMITH MD A PROF MED CORP
Entity Type:Organization
Organization Name:EDDIE SMITH MD A PROF MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-325-6226
Mailing Address - Street 1:103 PICCIOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-3572
Mailing Address - Country:US
Mailing Address - Phone:985-325-6226
Mailing Address - Fax:
Practice Address - Street 1:103 PICCIOLA PKWY
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-3572
Practice Address - Country:US
Practice Address - Phone:985-325-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1357464Medicaid
LA52453Medicare PIN
LAB63877Medicare UPIN