Healthcare Provider Details

I. General information

NPI: 1669549283
Provider Name (Legal Business Name): WEST JEFFERSON PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER BLVD SUITE S650
MARRERO LA
70072-3151
US

IV. Provider business mailing address

1111 MEDICAL CENTER BLVD SUITE S650
MARRERO LA
70072-3151
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-6504
  • Fax: 504-349-6528
Mailing address:
  • Phone: 504-349-6504
  • Fax: 504-349-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: HEIDI A GWINN
Title or Position: CREDENTIALING COORD.
Credential:
Phone: 504-349-1297