Provider Demographics
NPI:1700090016
Name:SLIDELL INTERNAL MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:SLIDELL INTERNAL MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:QUIBILAN
Authorized Official - Last Name:LARCENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-0123
Mailing Address - Street 1:105 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5544
Mailing Address - Country:US
Mailing Address - Phone:985-646-0123
Mailing Address - Fax:985-641-0330
Practice Address - Street 1:105 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 301
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5544
Practice Address - Country:US
Practice Address - Phone:985-646-0123
Practice Address - Fax:985-641-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11339R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1662097Medicaid
LA1662097Medicaid
LA5W341Medicare ID - Type Unspecified
LAG09158Medicare UPIN