Provider Demographics
NPI:1710078449
Name:JEFFERSON FAMILY MEDICAL CENTER ,LLC
Entity Type:Organization
Organization Name:JEFFERSON FAMILY MEDICAL CENTER ,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HEISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-926-4780
Mailing Address - Street 1:330 LEE DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-1601
Mailing Address - Country:US
Mailing Address - Phone:225-926-4780
Mailing Address - Fax:225-926-4783
Practice Address - Street 1:330 LEE DR.
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-1601
Practice Address - Country:US
Practice Address - Phone:225-926-4780
Practice Address - Fax:225-926-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12387R261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG55556Medicare UPIN