Provider Demographics
NPI:1912199670
Name:LSUHSC MEDICINE
Entity Type:Organization
Organization Name:LSUHSC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-568-3930
Mailing Address - Street 1:3101 CLEARY AVE
Mailing Address - Street 2:APT # 11
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-7308
Mailing Address - Country:US
Mailing Address - Phone:504-261-1789
Mailing Address - Fax:
Practice Address - Street 1:2020 GRAVIER ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2272
Practice Address - Country:US
Practice Address - Phone:504-568-3792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAGETP.LSU.IM261Q00000X, 281P00000X, 282N00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No281P00000XHospitalsChronic Disease Hospital
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1006831OtherMEDICAID PRESCRIBER