Provider Demographics
NPI:1598707150
Name:MISS LOU HEALTH LLC
Entity Type:Organization
Organization Name:MISS LOU HEALTH LLC
Other - Org Name:MISS LOU CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VIKRAMADITYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DULAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-304-9718
Mailing Address - Street 1:140 JEFFERSON DAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-5104
Mailing Address - Country:US
Mailing Address - Phone:601-304-9718
Mailing Address - Fax:601-304-9637
Practice Address - Street 1:140 JEFFERSON DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5104
Practice Address - Country:US
Practice Address - Phone:601-304-9718
Practice Address - Fax:601-304-9637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18344174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02602371Medicaid
1197785OtherLOUSISIANA MEDICAID
MS595597482OtherBLUE CROSS BLUE SHIELD