Provider Demographics
NPI:1104095959
Name:BRENT O CAMPANELLA, MD
Entity type:Organization
Organization Name:BRENT O CAMPANELLA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:O
Authorized Official - Last Name:CAMPANELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-769-0043
Mailing Address - Street 1:5131 ESSEN LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3541
Mailing Address - Country:US
Mailing Address - Phone:225-769-0043
Mailing Address - Fax:225-769-0133
Practice Address - Street 1:5131 ESSEN LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3541
Practice Address - Country:US
Practice Address - Phone:225-769-0043
Practice Address - Fax:225-769-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1393053Medicaid
LA5K369Medicare PIN
LA1393053Medicaid