Provider Demographics
NPI:1316064892
Name:ANDREW J MINARDI JR MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:ANDREW J MINARDI JR MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-468-5399
Mailing Address - Street 1:809 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554-2223
Mailing Address - Country:US
Mailing Address - Phone:337-468-5399
Mailing Address - Fax:888-317-2910
Practice Address - Street 1:809 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2223
Practice Address - Country:US
Practice Address - Phone:337-468-5399
Practice Address - Fax:888-317-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022318208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1495077Medicaid
LAG74309Medicare UPIN
LA1495077Medicaid