Provider Demographics
NPI:1215372594
Name:WOMAN'S CLINIC OF IBERIA
Entity type:Organization
Organization Name:WOMAN'S CLINIC OF IBERIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COPPAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-364-2383
Mailing Address - Street 1:2309 EAST MAIN STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560
Mailing Address - Country:US
Mailing Address - Phone:337-364-2383
Mailing Address - Fax:
Practice Address - Street 1:811 ALBERTSON PKWY
Practice Address - Street 2:SUITE F
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-5256
Practice Address - Country:US
Practice Address - Phone:337-330-2386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022088305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1451274Medicaid
LA57824Medicare PIN