Healthcare Provider Details

I. General information

NPI: 1689776205
Provider Name (Legal Business Name): ELLSWORTH JACK REMSON JD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16033 DOCTORS BLVD
HAMMOND LA
70403-1479
US

IV. Provider business mailing address

16033 DOCTORS BLVD
HAMMOND LA
70403-1479
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-1860
  • Fax:
Mailing address:
  • Phone: 985-230-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101051340
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number020915
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101051340
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: