Provider Demographics
NPI:1851609978
Name:PELICAN PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:PELICAN PHYSICIAN SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KUMAR
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:AMARANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-645-9000
Mailing Address - Street 1:2375 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4142
Mailing Address - Country:US
Mailing Address - Phone:985-645-9000
Mailing Address - Fax:985-645-0359
Practice Address - Street 1:2375 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4142
Practice Address - Country:US
Practice Address - Phone:985-645-9000
Practice Address - Fax:985-645-0359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06512R207PE0004X
LA019740207Q00000X
LA025659207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442119Medicaid
LA1442119Medicaid