Provider Demographics
NPI:1922048735
Name:PLAZA ORTHOPEDIC & SPORTS MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:PLAZA ORTHOPEDIC & SPORTS MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-542-1533
Mailing Address - Street 1:15781 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1452
Mailing Address - Country:US
Mailing Address - Phone:985-542-1533
Mailing Address - Fax:985-542-6713
Practice Address - Street 1:15781 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1452
Practice Address - Country:US
Practice Address - Phone:985-542-1533
Practice Address - Fax:985-542-6713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1949256Medicaid
LA1949256Medicaid
LA1257600001Medicare NSC