Provider Demographics
NPI:1902850035
Name:AFFINITY HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:AFFINITY HEALTH GROUP, LLC
Other - Org Name:ABRAHAM MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-361-0900
Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-9997
Practice Address - Street 1:261 HWY 132
Practice Address - Street 2:
Practice Address - City:MANGHAM
Practice Address - State:LA
Practice Address - Zip Code:71259-0219
Practice Address - Country:US
Practice Address - Phone:318-248-2807
Practice Address - Fax:318-248-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444162Medicaid
LA010064540OtherRAILROAD MEDICARE
LA439966080COtherBLUE CROSS BLUE SHIELD
LA5C838Medicare PIN
LA439966080COtherBLUE CROSS BLUE SHIELD