Provider Demographics
NPI:1952878506
Name:HOSPITAL SERVICE DISTRICT 1 OF EAST BATON ROUGE PARISH
Entity Type:Organization
Organization Name:HOSPITAL SERVICE DISTRICT 1 OF EAST BATON ROUGE PARISH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-570-2489
Mailing Address - Street 1:2335 CHURCH ST STE E
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-570-2489
Mailing Address - Fax:225-570-2986
Practice Address - Street 1:6550 MAIN ST STE 3500
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4092
Practice Address - Country:US
Practice Address - Phone:225-654-3607
Practice Address - Fax:225-658-2262
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL SERVICE DISTRICT 1 OF EAST BATON ROUGE PARISH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-31
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445126Medicaid