Healthcare Provider Details

I. General information

NPI: 1407281546
Provider Name (Legal Business Name): COMMUNITY MEDICAL GROUP-ST CHARLES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 PAUL MAILLARD RD SUITE2250
LULING LA
70070-4349
US

IV. Provider business mailing address

503 MCMILLAN RD
WEST MONROE LA
71291-5327
US

V. Phone/Fax

Practice location:
  • Phone: 985-785-2218
  • Fax: 985-785-7753
Mailing address:
  • Phone: 318-329-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN W MCDANIEL
Title or Position: CEO
Credential:
Phone: 504-522-2014