Provider Demographics
NPI:1063432524
Name:O E REAVILL M D, APMC
Entity type:Organization
Organization Name:O E REAVILL M D, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:E
Authorized Official - Last Name:REAVILL
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:337-264-1000
Mailing Address - Street 1:2501 W PINHOOK RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3346
Mailing Address - Country:US
Mailing Address - Phone:337-264-1000
Mailing Address - Fax:337-264-7830
Practice Address - Street 1:2501 W PINHOOK RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3346
Practice Address - Country:US
Practice Address - Phone:337-264-1000
Practice Address - Fax:337-264-7830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07184R261QM1300X, 261QP3300X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Not Answered261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Not Answered261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1947164Medicaid
LAB30702Medicare UPIN
LA1947164Medicaid
LA5J621Medicare ID - Type Unspecified
LAPIN 5J621CT47Medicare ID - Type UnspecifiedGROUP 5CT47