Healthcare Provider Details

I. General information

NPI: 1396068318
Provider Name (Legal Business Name): ELISE SCALLAN MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 BLUEBONNET BLVD SUITE 2121
BATON ROUGE LA
70810-7827
US

IV. Provider business mailing address

8080 BLUEBONNET BLVD SUITE 2121
BATON ROUGE LA
70810-7827
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-7200
  • Fax: 225-767-7386
Mailing address:
  • Phone: 225-767-7200
  • Fax: 225-767-7386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number023856
License Number StateLA

VIII. Authorized Official

Name: JUDY WHEAT
Title or Position: ADMINISTRATION
Credential:
Phone: 225-767-7200