Provider Demographics
NPI:1821089665
Name:ACADIANA SURGICAL CLINIC INC
Entity Type:Organization
Organization Name:ACADIANA SURGICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GLYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-948-7680
Mailing Address - Street 1:3975 I 49 S SERVICE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-0775
Mailing Address - Country:US
Mailing Address - Phone:337-948-7680
Mailing Address - Fax:337-948-1143
Practice Address - Street 1:3975 I 49 S SERVICE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-948-7680
Practice Address - Fax:337-948-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACN6611OtherRAILROAD MEDICARE
LA1457221Medicaid
LA1457221Medicaid