Healthcare Provider Details

I. General information

NPI: 1609320506
Provider Name (Legal Business Name): MID STATE ORTHOPAEDIC & SPORTS MEDICINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 NINTH ST STE A
JENA LA
71342-3900
US

IV. Provider business mailing address

3444 MASONIC DR
ALEXANDRIA LA
71301-3615
US

V. Phone/Fax

Practice location:
  • Phone: 318-473-9556
  • Fax: 318-441-8339
Mailing address:
  • Phone: 318-473-9556
  • Fax: 318-441-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number9317843
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number9317843
License Number StateLA

VIII. Authorized Official

Name: MARK A DODSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-473-9556