Provider Demographics
NPI:1881877835
Name:GREEN CLINIC SURGICAL HOSPITAL CRNA GROUP
Entity type:Organization
Organization Name:GREEN CLINIC SURGICAL HOSPITAL CRNA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-232-7700
Mailing Address - Street 1:1118 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5914
Mailing Address - Country:US
Mailing Address - Phone:318-232-7700
Mailing Address - Fax:318-232-1092
Practice Address - Street 1:1118 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5914
Practice Address - Country:US
Practice Address - Phone:318-232-7700
Practice Address - Fax:318-232-1092
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREEN CLINIC SURGICAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH4674OtherBLUE CROSS OF LA