Healthcare Provider Details

I. General information

NPI: 1114957172
Provider Name (Legal Business Name): PEDIATRIC GENERAL SURGERY APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 AMBASSADOR CAFFERY PKWY STE 202
LAFAYETTE LA
70508-6926
US

IV. Provider business mailing address

PO BOX 81932
LAFAYETTE LA
70598-1932
US

V. Phone/Fax

Practice location:
  • Phone: 337-983-2468
  • Fax: 337-983-2471
Mailing address:
  • Phone: 337-983-2468
  • Fax: 337-983-2471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH W FALTERMAN
Title or Position: OWNER
Credential: MD
Phone: 337-983-2468