Provider Demographics
NPI:1386664225
Name:SURGICAL CLINIC OF LOUISIANA LLC
Entity type:Organization
Organization Name:SURGICAL CLINIC OF LOUISIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:TREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:504-349-6860
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SOUTH 860
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-6860
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SOUTH 860
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA436248208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1440582Medicaid
LA5C718Medicare PIN
LA1440582Medicaid