Provider Demographics
NPI:1528108503
Name:ORTHO CLINIC - PROFESSIONAL MEDICAL
Entity type:Organization
Organization Name:ORTHO CLINIC - PROFESSIONAL MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LISECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:337-364-5310
Mailing Address - Street 1:516 JEFFERSON TER
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4980
Mailing Address - Country:US
Mailing Address - Phone:337-364-5310
Mailing Address - Fax:337-364-5313
Practice Address - Street 1:516 JEFFERSON TERRRACE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4948
Practice Address - Country:US
Practice Address - Phone:337-364-5310
Practice Address - Fax:337-364-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26008207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty