Healthcare Provider Details

I. General information

NPI: 1962636597
Provider Name (Legal Business Name): BAYOU PHYSICAL MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12038 LAKE SHERWOOD AVE N
BATON ROUGE LA
70816-4341
US

IV. Provider business mailing address

PO BOX 64800
BATON ROUGE LA
70896-4800
US

V. Phone/Fax

Practice location:
  • Phone: 225-247-6483
  • Fax:
Mailing address:
  • Phone: 225-247-6483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD.15662R
License Number StateLA

VIII. Authorized Official

Name: DR. ELSIE M COLIN
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 225-247-6483