MEDICARE: LOUISIANA SPINE SURGERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	15736A	LA

General Provider Information

NPI Number	:	1487815585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA SPINE SURGERY

Provider Business Mailing Address
First Line	:	113 SAINT THOMAS ST
Second Line	:	SUITE D
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4575
Country	:	US
Telephone Number	:	337-261-5453
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 SAINT THOMAS ST
Second Line	:	SUITE D
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4575
Country	:	US
Telephone Number	:	337-261-5453
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK FRANCIS MCDONNELL
Credential	:	MD
Telephone Number	:	337-261-5453

Provider Enumeration Date	:	06/20/2008
Last Update Date	:	06/26/2008

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