Provider Demographics
NPI:1669897609
Name:INDEPENDENCE MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:INDEPENDENCE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-338-4268
Mailing Address - Street 1:7300 LAKESHORE DR APT 10
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-2462
Mailing Address - Country:US
Mailing Address - Phone:504-338-4268
Mailing Address - Fax:
Practice Address - Street 1:281 W 4TH ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2386
Practice Address - Country:US
Practice Address - Phone:504-338-4268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1910864Medicaid