Healthcare Provider Details

I. General information

NPI: 1114356979
Provider Name (Legal Business Name): BATON ROUGE GENERAL PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 FLORIDA BLVD
BATON ROUGE LA
70806-4130
US

IV. Provider business mailing address

8490 PICARDY AVE BLDG 200
BATON ROUGE LA
70809-3731
US

V. Phone/Fax

Practice location:
  • Phone: 225-367-4558
  • Fax: 225-367-4576
Mailing address:
  • Phone: 225-237-1754
  • Fax: 225-237-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KENDALL JOHNSON
Title or Position: C.F.O.
Credential:
Phone: 225-237-1645