Provider Demographics
NPI:1265433320
Name:WESTSIDE CLINICS ANC
Entity type:Organization
Organization Name:WESTSIDE CLINICS ANC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN & PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:H
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-391-7337
Mailing Address - Street 1:P O BOX 2400
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-2400
Mailing Address - Country:US
Mailing Address - Phone:504-391-7337
Mailing Address - Fax:504-398-7213
Practice Address - Street 1:4225 LAPALCO BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-391-7337
Practice Address - Fax:504-398-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1440574Medicaid