Healthcare Provider Details

I. General information

NPI: 1598267262
Provider Name (Legal Business Name): BATON ROUGE INTERVENTIONAL PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 BLUEBONNET BLVD STE A
BATON ROUGE LA
70809-9658
US

IV. Provider business mailing address

PO BOX 77878
BATON ROUGE LA
70879-7878
US

V. Phone/Fax

Practice location:
  • Phone: 225-442-3166
  • Fax:
Mailing address:
  • Phone: 225-442-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY S. MCDANIEL JR.
Title or Position: OWNER
Credential: MD
Phone: 225-442-3166