Basic Information
| Provider Information | |||||||||
| NPI: | 1609035286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAIBORNE MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | A PROFESSIONAL MEDICAL CORPORATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048919800 | ||||||||
| FaxNumber: | 5044610030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048919800 | ||||||||
| FaxNumber: | 5044610030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 10/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | AFZAL | ||||||||
| AuthorizedOfficialFirstName: | FIAZ | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5048919800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 11980R | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1687553 | 05 | LA | MEDICAID |