Provider Demographics
NPI:1972513117
Name:MED-PEDS ASSOCIATES APMC
Entity type:Organization
Organization Name:MED-PEDS ASSOCIATES APMC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-845-0004
Mailing Address - Street 1:4700 LOUISIANA HWY 22
Mailing Address - Street 2:PMB 604
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-845-0004
Mailing Address - Fax:985-845-0870
Practice Address - Street 1:804 HEAVENS DR
Practice Address - Street 2:SUITE 106
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-845-0004
Practice Address - Fax:985-845-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445975Medicaid
LA1445975Medicaid