Healthcare Provider Details

I. General information

NPI: 1174624712
Provider Name (Legal Business Name): JON V. SCHELLACK, M.D. (A PROFESSIONAL MEDICAL CORPORATION)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 BRITTANY DR # B
BATON ROUGE LA
70808-9144
US

IV. Provider business mailing address

5425 BRITTANY DR # B
BATON ROUGE LA
70808-9144
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-5479
  • Fax: 225-767-5147
Mailing address:
  • Phone: 225-767-5479
  • Fax: 225-767-5147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JON V SCHELLACK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 225-767-5479