Basic Information
| Provider Information | |||||||||
| NPI: | 1205888914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-LOUISIANA ANESTHESIA CONSULTANTS, APMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 5887 | ||||||||
| Address2: | 1444 PETERMAN DRIVE | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713075887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184425399 | ||||||||
| FaxNumber: | 3184421586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1444 PETERMAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184425399 | ||||||||
| FaxNumber: | 3184421586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | NEELY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | WARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3184425399 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1941484 | 05 | LA | MEDICAID |