Provider Demographics
NPI:1639218407
Name:LAKE CHARLES MEDICAL SERVICES ORTHOPEDICS LLC
Entity Type:Organization
Organization Name:LAKE CHARLES MEDICAL SERVICES ORTHOPEDICS LLC
Other - Org Name:D DREZ MD AND S HOFER DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. V.P. BUSINESS DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:USHER
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:337-494-3200
Mailing Address - Street 1:1717 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8991
Mailing Address - Country:US
Mailing Address - Phone:337-494-4900
Mailing Address - Fax:337-494-4936
Practice Address - Street 1:1717 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8991
Practice Address - Country:US
Practice Address - Phone:337-494-4900
Practice Address - Fax:337-494-4936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE CHARLES MEDICAL SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADF6777OtherRAILROAD MCR
LANH6097OtherBCBS
LA07-00010827OtherOCCUPATIONAL LICENSE
LA1030422Medicaid
LANH6097OtherBCBS