Basic Information
| Provider Information | |||||||||
| NPI: | 1477644359 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST TAMMANY COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855852 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 14TH ST | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704582944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856498775 | ||||||||
| FaxNumber: | 9856498703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | DIXIT | ||||||||
| AuthorizedOfficialFirstName: | MADHURI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 9857855852 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST CHARLES COMMUNITY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD10981R | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1452904 | 05 | LA | MEDICAID | 1925349 | 05 | LA | MEDICAID | 1579483 | 05 | LA | MEDICAID | 1444642 | 05 | LA | MEDICAID | 1945421 | 05 | LA | MEDICAID |