Provider Demographics
NPI:1578804936
Name:PONTCHARTRAIN ANESTHESIA, LLC
Entity Type:Organization
Organization Name:PONTCHARTRAIN ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOURCADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-781-8565
Mailing Address - Street 1:75024 EMERYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ABITA SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70420-2700
Mailing Address - Country:US
Mailing Address - Phone:504-231-3957
Mailing Address - Fax:
Practice Address - Street 1:2781 CT SWITZER SR DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531
Practice Address - Country:US
Practice Address - Phone:228-388-4585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2354779Medicaid