Provider Demographics
NPI:1881727691
Name:PONTCHARTRAIN PEDIATRICS LLC
Entity type:Organization
Organization Name:PONTCHARTRAIN PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-893-8505
Mailing Address - Street 1:4405 HIGHWAY 190 EAST SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4957
Mailing Address - Country:US
Mailing Address - Phone:985-893-8505
Mailing Address - Fax:985-893-0093
Practice Address - Street 1:4405 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4957
Practice Address - Country:US
Practice Address - Phone:985-893-8505
Practice Address - Fax:985-893-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442810Medicaid