Healthcare Provider Details

I. General information

NPI: 1225449374
Provider Name (Legal Business Name): CAPITAL CITY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7049 PERKINS RD
BATON ROUGE LA
70808
US

IV. Provider business mailing address

3838 N CAUSEWAY BLVD SUITE 2550
METAIRIE LA
70002-8194
US

V. Phone/Fax

Practice location:
  • Phone: 225-926-7200
  • Fax: 225-706-2182
Mailing address:
  • Phone: 504-681-8259
  • Fax: 504-681-8260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER ALDEN KELLOGG
Title or Position: ASSOCIATE GENERAL COUNSEL
Credential:
Phone: 504-681-8532