Provider Demographics
NPI:1710052378
Name:AUDUBON PEDIATRICS, LLC
Entity Type:Organization
Organization Name:AUDUBON PEDIATRICS, LLC
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-688-0238
Mailing Address - Street 1:216 MYSTIC BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2870
Mailing Address - Country:US
Mailing Address - Phone:985-868-9339
Mailing Address - Fax:
Practice Address - Street 1:216 MYSTIC BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2870
Practice Address - Country:US
Practice Address - Phone:985-868-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.024810208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1459313Medicaid