Provider Demographics
NPI:1598060733
Name:HEART CLINIC OF HAMMOND
Entity Type:Organization
Organization Name:HEART CLINIC OF HAMMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GHIATH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKDADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-270-2733
Mailing Address - Street 1:16033 DOCTORS BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1479
Mailing Address - Country:US
Mailing Address - Phone:985-974-9278
Mailing Address - Fax:985-542-6341
Practice Address - Street 1:16033 DOCTORS BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1479
Practice Address - Country:US
Practice Address - Phone:985-974-9278
Practice Address - Fax:985-542-6341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11934R207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2142976Medicaid