Provider Demographics
NPI:1013486059
Name:PHYSICIAN GROUP OF LOUISIANA INC
Entity type:Organization
Organization Name:PHYSICIAN GROUP OF LOUISIANA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-467-1072
Mailing Address - Street 1:PO BOX 281796
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1796
Mailing Address - Country:US
Mailing Address - Phone:866-243-7107
Mailing Address - Fax:314-432-9683
Practice Address - Street 1:1900 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4416
Practice Address - Country:US
Practice Address - Phone:318-651-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty