Healthcare Provider Details

I. General information

NPI: 1245275809
Provider Name (Legal Business Name): FAIRWAY PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 HIGHWAY 190 SUITE C
COVINGTON LA
70433-4954
US

IV. Provider business mailing address

7020 HIGHWAY 190 SUITE C
COVINGTON LA
70433-4954
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-7337
  • Fax: 985-871-7600
Mailing address:
  • Phone: 985-871-7337
  • Fax: 985-871-7600

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. KATHRYN QUARLS
Title or Position: ADMINISTRATING PHYSICIAN
Credential: M.D.
Phone: 985-871-7337