Provider Demographics
NPI:1336209550
Name:J H FAIRBANKS MD PLLC
Entity Type:Organization
Organization Name:J H FAIRBANKS MD PLLC
Other - Org Name:RIVERPARK SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-336-2212
Mailing Address - Street 1:107 FRONT ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:39120
Mailing Address - Country:US
Mailing Address - Phone:318-336-2212
Mailing Address - Fax:318-336-6067
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:SUITE 230
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:39120
Practice Address - Country:US
Practice Address - Phone:318-336-2212
Practice Address - Fax:318-336-6067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J H FAIRBANKS MD PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD017268207X00000X, 207XX0005X
MS15703207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119142Medicaid
LA1384101Medicaid
LA1384101Medicaid
LA4F313Medicare ID - Type Unspecified