Healthcare Provider Details

I. General information

NPI: 1366683971
Provider Name (Legal Business Name): AUDUBON PATHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 WHITNEY AVE BLDG 3
GRETNA LA
70056-5011
US

IV. Provider business mailing address

1141 WHITNEY AVE BLDG 3
GRETNA LA
70056-5011
US

V. Phone/Fax

Practice location:
  • Phone: 504-361-3757
  • Fax: 504-361-3132
Mailing address:
  • Phone: 504-361-3757
  • Fax: 504-361-3132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number023755
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number023755
License Number StateLA

VIII. Authorized Official

Name: DR. WILLIAM P LONG
Title or Position: OWNER
Credential: MD
Phone: 504-361-3757