Basic Information
| Provider Information | |||||||||
| NPI: | 1477734424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR INSTITUTE OF THE SOUTH, APMC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY DOCTORS CLINIC OF MATHEWS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 DUNN ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703604413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858735669 | ||||||||
| FaxNumber: | 9858720317 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 ACADIA PARK DR | ||||||||
| Address2: | |||||||||
| City: | RACELAND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703942619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9855377575 | ||||||||
| FaxNumber: | 9855377584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KONUR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9858760300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOVASCULAR INSTITUTE OF THE SOUTH, APMC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 1447943 | 05 | LA | MEDICAID |