Healthcare Provider Details

I. General information

NPI: 1760612865
Provider Name (Legal Business Name): SOUTHERN UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 COOLIDGE BLVD
LAFAYETTE LA
70503-2436
US

IV. Provider business mailing address

PO BOX 54028
LAFAYETTE LA
70505-4028
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-6665
  • Fax: 337-233-0327
Mailing address:
  • Phone: 337-233-6665
  • Fax: 337-233-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD F BREAUX
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 337-233-6665