Healthcare Provider Details

I. General information

NPI: 1154300275
Provider Name (Legal Business Name): MINDEN INTERNAL MEDICINE & PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OFFICE PARK DR
MINDEN LA
71055-3088
US

IV. Provider business mailing address

101 OFFICE PARK DR
MINDEN LA
71055-3088
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-2979
  • Fax: 318-377-2596
Mailing address:
  • Phone: 318-377-2979
  • Fax: 318-377-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: DR. KELLY M CARLISLE
Title or Position: OWNER
Credential: MD
Phone: 318-377-2979