Provider Demographics
NPI:1992882237
Name:NORTHSHORE INTERNAL MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:NORTHSHORE INTERNAL MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BODEWALDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-318-1000
Mailing Address - Street 1:2101 ROBIN AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5772
Mailing Address - Country:US
Mailing Address - Phone:985-318-1000
Mailing Address - Fax:985-318-1001
Practice Address - Street 1:2101 ROBIN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5772
Practice Address - Country:US
Practice Address - Phone:985-318-1000
Practice Address - Fax:985-318-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1440621Medicaid
LA5C931Medicare ID - Type Unspecified