Healthcare Provider Details

I. General information

NPI: 1902821861
Provider Name (Legal Business Name): PIERRE G. DETIEGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 INDUSTRIAL BLVD
HARVEY LA
70058-2314
US

IV. Provider business mailing address

1816 INDUSTRIAL BLVD
HARVEY LA
70058-2314
US

V. Phone/Fax

Practice location:
  • Phone: 504-366-7638
  • Fax: 504-366-1029
Mailing address:
  • Phone: 504-366-7638
  • Fax: 504-366-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD070246L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD201664
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME81323
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: