Provider Demographics
NPI:1568764124
Name:NORTHLAKE CARDIOLOGY DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:NORTHLAKE CARDIOLOGY DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MADAELIL
Authorized Official - Middle Name:G
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-649-2883
Mailing Address - Street 1:1150 ROBERT BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2004
Mailing Address - Country:US
Mailing Address - Phone:985-649-2883
Mailing Address - Fax:985-649-2953
Practice Address - Street 1:1150 ROBERT BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2004
Practice Address - Country:US
Practice Address - Phone:985-649-2883
Practice Address - Fax:985-649-2953
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHLAKE CARDIOLOGY ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05592R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1316067Medicaid
LA1316067Medicaid
LA5M941Medicare PIN