Basic Information
| Provider Information | |||||||||
| NPI: | 1902850035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFINITY HEALTH GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ABRAHAM MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188129997 | ||||||||
| Practice Location | |||||||||
| Address1: | 261 HWY 132 | ||||||||
| Address2: | |||||||||
| City: | MANGHAM | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712590219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182482807 | ||||||||
| FaxNumber: | 3182482967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | BREARD | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3183610900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1444162 | 05 | LA | MEDICAID | 010064540 | 01 | LA | RAILROAD MEDICARE | OTHER | 439966080C | 01 | LA | BLUE CROSS BLUE SHIELD | OTHER |