Provider Demographics
NPI:1598311029
Name:SOUTHERN LOUISIANA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHERN LOUISIANA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-229-7451
Mailing Address - Street 1:PO BOX 7462
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70469-7462
Mailing Address - Country:US
Mailing Address - Phone:985-643-4575
Mailing Address - Fax:833-222-4520
Practice Address - Street 1:2104 GAUSE BLVD W STE A
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-4130
Practice Address - Country:US
Practice Address - Phone:985-643-4575
Practice Address - Fax:833-222-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA27-2182406OtherTAX ID