Healthcare Provider Details

I. General information

NPI: 1760734685
Provider Name (Legal Business Name): PONTCHARTRAIN DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 JUDGE TANNER BLVD
COVINGTON LA
70433-7500
US

IV. Provider business mailing address

681 BOCAGE LN
MANDEVILLE LA
70471-1605
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-4050
  • Fax:
Mailing address:
  • Phone: 985-792-5537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL DAVID HALL
Title or Position: RADIOLOGIST
Credential: M.D.
Phone: 985-792-5537