Provider Demographics
NPI: | 1710944012 |
---|---|
Name: | SOUTH LOUISIANA MEDICAL ASSOCIATES |
Entity Type: | Organization |
Organization Name: | SOUTH LOUISIANA MEDICAL ASSOCIATES |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO MEDICAL DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | GARCIA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 985-868-9300 |
Mailing Address - Street 1: | 1990 INDUSTRIAL BOULEVARD |
Mailing Address - Street 2: | |
Mailing Address - City: | HOUMA |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 70363-7055 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 985-868-9300 |
Mailing Address - Fax: | 985-851-0053 |
Practice Address - Street 1: | 1990 INDUSTRIAL BOULEVARD |
Practice Address - Street 2: | |
Practice Address - City: | HOUMA |
Practice Address - State: | LA |
Practice Address - Zip Code: | 70363-7055 |
Practice Address - Country: | US |
Practice Address - Phone: | 985-868-9300 |
Practice Address - Fax: | 985-851-0053 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-04-28 |
Last Update Date: | 2019-02-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | 207Q00000X, 207R00000X, 207RC0000X, 207RG0100X, 207RH0003X, 207RI0200X, 207RP1001X, 2080P0206X, 208800000X, 213ES0103X, 363A00000X, 363L00000X, 363LF0000X, 363LW0102X | |
208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LW0102X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
LA | 1441830 | Medicaid | |
LA | 1441830 | Medicaid | |
LA | 1441830 | Medicaid |