Healthcare Provider Details

I. General information

NPI: 1609334390
Provider Name (Legal Business Name): SOUTHSIDE PEDIATRICS. A.P.M.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 ALBERTSON PKWY STE A
BROUSSARD LA
70518-5256
US

IV. Provider business mailing address

811 ALBERTSON PKWY STE A
BROUSSARD LA
70518-5256
US

V. Phone/Fax

Practice location:
  • Phone: 337-839-2238
  • Fax:
Mailing address:
  • Phone: 337-839-2238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLOS BRUNO
Title or Position: PRESIDENT
Credential: MD
Phone: 337-839-2238