Healthcare Provider Details

I. General information

NPI: 1588678494
Provider Name (Legal Business Name): INTERNAL MEDICINE CLINIC OF TANGIPAHOA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42388 PELICAN PROFESSIONAL PARK
HAMMOND LA
70403
US

IV. Provider business mailing address

PO BOX 1799
HAMMOND LA
70404-1799
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-6251
  • Fax: 985-345-2386
Mailing address:
  • Phone: 985-542-6251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS C STEVENS
Title or Position: PARTNER
Credential: MD
Phone: 985-542-6251