Provider Demographics
NPI:1295050599
Name:NORTHSHORE REDI-MED LLC
Entity type:Organization
Organization Name:NORTHSHORE REDI-MED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NAEEM
Authorized Official - Suffix:
Authorized Official - Credentials:AO
Authorized Official - Phone:985-626-3470
Mailing Address - Street 1:4430 HWY 22
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-626-3470
Mailing Address - Fax:985-674-5377
Practice Address - Street 1:4430 HWY 22
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-626-3470
Practice Address - Fax:985-674-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10199R207Q00000X
LA11006R207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1652539Medicaid
LA2167529Medicaid
LA56995Medicare UPIN
LA2167529Medicaid