Basic Information
| Provider Information | |||||||||
| NPI: | 1982002911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFINITY HEALTH GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTERNAL MEDICINE 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: | 3188126603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2516 BROADMOOR BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712012988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189980353 | ||||||||
| FaxNumber: | 3189980357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2014 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | BREARD | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3183610900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 013918 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.