Provider Demographics
NPI:1609002849
Name:BATON ROUGE SPORTS MEDICINE CLINIC, LLC
Entity Type:Organization
Organization Name:BATON ROUGE SPORTS MEDICINE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:DUGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-216-3047
Mailing Address - Street 1:720 CONNELLS PARK LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6522
Mailing Address - Country:US
Mailing Address - Phone:225-216-3047
Mailing Address - Fax:225-928-7054
Practice Address - Street 1:720 CONNELLS PARK LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6522
Practice Address - Country:US
Practice Address - Phone:225-216-3047
Practice Address - Fax:225-928-7054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17260207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457281Medicaid
LAE68302Medicare UPIN
LA1457281Medicaid