Provider Demographics
NPI:1821042086
Name:SULPHUR PEDIATRIC CLINIC MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SULPHUR PEDIATRIC CLINIC MEDICAL CORPORATION
Other - Org Name:THE PEDIATRIC CENTER OF SW LA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:RICHERT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:337-527-6371
Mailing Address - Street 1:600 CYPRESS STREET
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5052
Mailing Address - Country:US
Mailing Address - Phone:337-527-6371
Mailing Address - Fax:337-528-9616
Practice Address - Street 1:600 CYPRESS STREET
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5052
Practice Address - Country:US
Practice Address - Phone:337-527-6371
Practice Address - Fax:337-528-9616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
LA011494208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1948195Medicaid
LA5C373Medicare ID - Type Unspecified