Provider Demographics
NPI:1972642197
Name:JEFFERSON PEDIATRIC CLINIC
Entity type:Organization
Organization Name:JEFFERSON PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTTY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:OUBRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-349-6813
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE N-813
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-6813
Mailing Address - Fax:504-349-6832
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE N-813
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6813
Practice Address - Fax:504-349-6832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06128R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty