Provider Demographics
NPI:1568910503
Name:THIBODAUX EMERGENCY PHYSICIANS GROUP LLC
Entity Type:Organization
Organization Name:THIBODAUX EMERGENCY PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-534-0952
Mailing Address - Street 1:PO BOX 720487
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4358
Mailing Address - Country:US
Mailing Address - Phone:405-240-9381
Mailing Address - Fax:405-341-9217
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4823
Practice Address - Country:US
Practice Address - Phone:985-447-5500
Practice Address - Fax:904-265-8181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty