Healthcare Provider Details

I. General information

NPI: 1649703406
Provider Name (Legal Business Name): AMBER MEDINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 MEDICAL CENTER DR
BATON ROUGE LA
70816-3246
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 225-755-4950
  • Fax: 225-755-4807
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number320481
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: