Provider Demographics
NPI:1912967316
Name:KENNETH J. CHAMPAGNE, M.D., APMC
Entity Type:Organization
Organization Name:KENNETH J. CHAMPAGNE, M.D., APMC
Other - Org Name:COLON AND RECTAL CLINIC OF ACADIANA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:337-233-0219
Mailing Address - Street 1:102 DRURY LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5702
Mailing Address - Country:US
Mailing Address - Phone:372-233-0219
Mailing Address - Fax:337-233-2418
Practice Address - Street 1:102 DRURY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5702
Practice Address - Country:US
Practice Address - Phone:337-233-0219
Practice Address - Fax:337-233-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017238208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADG9731OtherREILROAD MEDICARE
LA1396681Medicaid
LA57395Medicare PIN