Healthcare Provider Details

I. General information

NPI: 1265630826
Provider Name (Legal Business Name): CHAD BENJAMIN VANASSELBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 S TYLER ST SUITE 200
COVINGTON LA
70433
US

IV. Provider business mailing address

1203 S TYLER ST SUITE 200
COVINGTON LA
70433-2353
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-9143
  • Fax: 985-892-9656
Mailing address:
  • Phone: 985-892-9143
  • Fax: 985-892-9656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT-1994
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number206801
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number206801
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: