Provider Demographics
NPI:1922194232
Name:THIBODAUX ORTHOPAEDIC AND SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:THIBODAUX ORTHOPAEDIC AND SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-446-6284
Mailing Address - Street 1:525 SAINT MARY ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2627
Mailing Address - Country:US
Mailing Address - Phone:985-446-6284
Mailing Address - Fax:
Practice Address - Street 1:525 SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2627
Practice Address - Country:US
Practice Address - Phone:985-446-6284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
013892174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1446611Medicaid
LA5D244Medicare PIN
0435980001Medicare NSC