Healthcare Provider Details

I. General information

NPI: 1477888774
Provider Name (Legal Business Name): OUTPATIENT PHYSICIAN PRACTICE NO 5
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HALL ST
MONROE LA
71201-7531
US

IV. Provider business mailing address

PO BOX 3249
MONROE LA
71210-3249
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-7337
  • Fax:
Mailing address:
  • Phone: 318-396-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: RONALD HOGAN
Title or Position: SR VP & CFO
Credential:
Phone: 318-966-7369