Provider Demographics
NPI:1619969292
Name:LOUISIANA NEUROLOGIC CLINIC AMC
Entity Type:Organization
Organization Name:LOUISIANA NEUROLOGIC CLINIC AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRZYSZTOF
Authorized Official - Middle Name:K
Authorized Official - Last Name:KUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-797-5400
Mailing Address - Street 1:1666 E BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5714
Mailing Address - Country:US
Mailing Address - Phone:318-797-5400
Mailing Address - Fax:318-797-5405
Practice Address - Street 1:1666 E BERT KOUNS LOOP
Practice Address - Street 2:SUITE 140
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5714
Practice Address - Country:US
Practice Address - Phone:318-797-5400
Practice Address - Fax:318-797-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1661970Medicaid
LA1661970Medicaid
LA5CW57Medicare PIN