Provider Demographics
NPI:1841521200
Name:ST. JAMES PRIMARY CARE
Entity type:Organization
Organization Name:ST. JAMES PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANU
Authorized Official - Middle Name:P
Authorized Official - Last Name:VELLANKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-907-3220
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:GRAMERCY
Mailing Address - State:LA
Mailing Address - Zip Code:70052-0419
Mailing Address - Country:US
Mailing Address - Phone:225-869-9200
Mailing Address - Fax:225-869-9241
Practice Address - Street 1:106 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-4337
Practice Address - Country:US
Practice Address - Phone:225-473-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JAMES PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-26
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12855R207R00000X
LA203358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1822141Medicaid
LA6650933750OtherBLUE CROSS
LA1822141Medicaid