Provider Demographics
NPI:1891725867
Name:MICHAEL H. VANDERLICK M.D. APMC
Entity Type:Organization
Organization Name:MICHAEL H. VANDERLICK M.D. APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:VANDERLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-291-1162
Mailing Address - Street 1:601 W SAINT MARY BLVD
Mailing Address - Street 2:STE. 210
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3568
Mailing Address - Country:US
Mailing Address - Phone:337-291-1162
Mailing Address - Fax:337-264-1499
Practice Address - Street 1:601 W SAINT MARY BLVD
Practice Address - Street 2:STE. 210
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3568
Practice Address - Country:US
Practice Address - Phone:337-291-1162
Practice Address - Fax:337-264-1499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14489R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CB74Medicare PIN