Provider Demographics
NPI:1841343159
Name:GREAT BEGINNINGS PEDIATRIC & ADOLESCENT MEDICINE, APMC
Entity type:Organization
Organization Name:GREAT BEGINNINGS PEDIATRIC & ADOLESCENT MEDICINE, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-407-2795
Mailing Address - Street 1:3975 INTERSTATE 49 S SERVICE RD
Mailing Address - Street 2:STE 201
Mailing Address - City:OPELOUAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-0775
Mailing Address - Country:US
Mailing Address - Phone:337-407-2795
Mailing Address - Fax:337-407-2798
Practice Address - Street 1:3975 INTERSTATE 49 S SERVICE RD
Practice Address - Street 2:STE 201
Practice Address - City:OPELOUAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-407-2795
Practice Address - Fax:337-407-2798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13641R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449627Medicaid