Provider Demographics
NPI:1255377297
Name:NORTHEAST LOUISIANA RADIOLOGY ASSOCIATES
Entity type:Organization
Organization Name:NORTHEAST LOUISIANA RADIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-283-4483
Mailing Address - Street 1:1813 NORTHPOINTE LN
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3879
Mailing Address - Country:US
Mailing Address - Phone:318-255-7591
Mailing Address - Fax:318-255-7584
Practice Address - Street 1:1813 NORTHPOINTE LN
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3879
Practice Address - Country:US
Practice Address - Phone:318-255-7591
Practice Address - Fax:318-255-7584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CF8948OtherRAILROAD MEDICARE
AR137419002Medicaid
LA1949523Medicaid
LA5C546Medicare PIN