Provider Demographics
NPI:1720071590
Name:NORTHWEST LOUSIANA PHYSCIAL MEDICINE
Entity Type:Organization
Organization Name:NORTHWEST LOUSIANA PHYSCIAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNESS
Authorized Official - Middle Name:
Authorized Official - Last Name:COURTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-424-4224
Mailing Address - Street 1:1801 FAIRFIELD AVE
Mailing Address - Street 2:STE 411
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4443
Mailing Address - Country:US
Mailing Address - Phone:318-424-4224
Mailing Address - Fax:318-424-4044
Practice Address - Street 1:1801 FAIRFIELD AVE
Practice Address - Street 2:STE 411
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4443
Practice Address - Country:US
Practice Address - Phone:318-424-4224
Practice Address - Fax:318-424-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CC56Medicare ID - Type Unspecified