Healthcare Provider Details

I. General information

NPI: 1205264868
Provider Name (Legal Business Name): COMMUNITY MEDICAL GROUP- ST BERNARD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8050 W JUDGE PEREZ DR SUITE 2300
CHALMETTE LA
70043-1734
US

IV. Provider business mailing address

PO BOX 789
OCEAN SPRINGS MS
39566-0789
US

V. Phone/Fax

Practice location:
  • Phone: 504-826-9655
  • Fax: 504-826-9656
Mailing address:
  • Phone: 228-818-0563
  • Fax: 228-818-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN W MCDANIEL
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 504-522-2014