Healthcare Provider Details

I. General information

NPI: 1346360013
Provider Name (Legal Business Name): FAMILY MEDICAL CLINIC OF MER ROUGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SOUTH DAVENPORT AVE
MER ROUGE LA
71261
US

IV. Provider business mailing address

205 S DAVENPORT AVENUE
MER ROUGE LA
71261
US

V. Phone/Fax

Practice location:
  • Phone: 318-647-3720
  • Fax: 318-647-5728
Mailing address:
  • Phone: 318-647-3720
  • Fax: 318-647-5728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number017205
License Number StateLA

VIII. Authorized Official

Name: DR. GEORGE WYATT WEBB
Title or Position: OWNER
Credential: M. D.
Phone: 318-647-3720