Provider Demographics
NPI:1669605721
Name:MEDA COLVIN LLC
Entity type:Organization
Organization Name:MEDA COLVIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MEDA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-319-8578
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD.
Mailing Address - Street 2:SUITE SOUTH 555
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-0000
Mailing Address - Country:US
Mailing Address - Phone:504-934-8110
Mailing Address - Fax:504-934-8188
Practice Address - Street 1:1111 MEDICAL CENTER BLVD.
Practice Address - Street 2:SUITE SOUTH 555
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-0000
Practice Address - Country:US
Practice Address - Phone:504-934-8110
Practice Address - Fax:504-934-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD019520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1976938Medicaid
LA1976938Medicaid
LA5R646B422Medicare PIN