Provider Demographics
NPI:1871630236
Name:PATRICK C HAGEN EAR, NOSE, THROAT & SINUS CLINIC
Entity Type:Organization
Organization Name:PATRICK C HAGEN EAR, NOSE, THROAT & SINUS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PONVELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-639-2519
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-0146
Mailing Address - Country:US
Mailing Address - Phone:800-639-2519
Mailing Address - Fax:985-447-8556
Practice Address - Street 1:2000 AUDUBON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5075
Practice Address - Country:US
Practice Address - Phone:985-446-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CH20Medicare ID - Type UnspecifiedMEDICARE