Provider Demographics
NPI:1962712521
Name:CHILDREN'S HOSPITAL MEDICAL PRACTICE CORPORATION
Entity type:Organization
Organization Name:CHILDREN'S HOSPITAL MEDICAL PRACTICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-894-6771
Mailing Address - Street 1:298 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5720
Mailing Address - Country:US
Mailing Address - Phone:504-896-9827
Mailing Address - Fax:504-894-5370
Practice Address - Street 1:298 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-896-9827
Practice Address - Fax:504-894-5370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-18
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA256207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1946711Medicaid
LA1946711Medicaid