Provider Demographics
NPI:1932448354
Name:IMPERIAL CALCASIEU MEDICAL GROUP
Entity Type:Organization
Organization Name:IMPERIAL CALCASIEU MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKINGBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-433-8400
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8284
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:921 1ST AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3424
Practice Address - Country:US
Practice Address - Phone:337-527-6385
Practice Address - Fax:337-527-3527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty