Provider Demographics
NPI:1588678494
Name:INTERNAL MEDICINE CLINIC OF TANGIPAHOA, LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CLINIC OF TANGIPAHOA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-542-6251
Mailing Address - Street 1:PO BOX 1799
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-1799
Mailing Address - Country:US
Mailing Address - Phone:985-542-6251
Mailing Address - Fax:
Practice Address - Street 1:42388 PELICAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:985-542-6251
Practice Address - Fax:985-345-2386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA10664-EQT2OtherPODIATRY X-RAY REG #
LA19D0997591OtherMAIN LAB CLIA #
LA5CB03OtherGROUP NUMBER
LA1442933Medicaid
LA10664-EQT1OtherX-RAY REG #
LA5CB03Medicare ID - Type UnspecifiedMEDICARE GROUP #
LA1442933Medicaid
LA19D0997591OtherMAIN LAB CLIA #