Healthcare Provider Details

I. General information

NPI: 1245272541
Provider Name (Legal Business Name): GASTROENTEROLOGY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 CHEROKEE ROSE LN
COVINGTON LA
70433-7195
US

IV. Provider business mailing address

PO BOX 848778
BOSTON MA
02284-8778
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-1721
  • Fax: 985-871-4049
Mailing address:
  • Phone: 985-871-1721
  • Fax: 985-893-6908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: HAZEL BRAUEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 985-871-1721