Provider Demographics
NPI:1205264868
Name:COMMUNITY MEDICAL GROUP- ST BERNARD INC
Entity type:Organization
Organization Name:COMMUNITY MEDICAL GROUP- ST BERNARD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-522-2014
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-0789
Mailing Address - Country:US
Mailing Address - Phone:228-818-0563
Mailing Address - Fax:228-818-0519
Practice Address - Street 1:8050 W JUDGE PEREZ DR
Practice Address - Street 2:SUITE 2300
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-1734
Practice Address - Country:US
Practice Address - Phone:504-826-9655
Practice Address - Fax:504-826-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA331631OtherMEDICARE PTAN