Provider Demographics
NPI:1427305788
Name:RONALD J. KLUCHIN, M.D.,A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:RONALD J. KLUCHIN, M.D.,A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/INTERNAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KLUCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-626-8110
Mailing Address - Street 1:784 ASBURY DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1844
Mailing Address - Country:US
Mailing Address - Phone:985-626-8110
Mailing Address - Fax:985-626-8423
Practice Address - Street 1:784 ASBURY DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-1844
Practice Address - Country:US
Practice Address - Phone:985-626-8110
Practice Address - Fax:985-626-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017699261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1386057Medicaid
LA55198Medicare PIN
LA1386057Medicaid