Provider Demographics
NPI:1689630121
Name:HEART CLINIC OF LOUISIANA DIAGNOSTIC SERVICES, APMC
Entity Type:Organization
Organization Name:HEART CLINIC OF LOUISIANA DIAGNOSTIC SERVICES, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:G
Authorized Official - Last Name:KUSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-349-6800
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:N 613
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-6800
Mailing Address - Fax:504-349-6621
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:N 613
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6800
Practice Address - Fax:504-349-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1799793Medicaid
LA1799793Medicaid