Healthcare Provider Details

I. General information

NPI: 1962675272
Provider Name (Legal Business Name): FAMILY MEDICINE SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 HIGHWAY 182 E STE 200
MORGAN CITY LA
70380-2038
US

IV. Provider business mailing address

6322 HIGHWAY 182 E
MORGAN CITY LA
70380-2038
US

V. Phone/Fax

Practice location:
  • Phone: 985-702-1220
  • Fax: 985-702-9715
Mailing address:
  • Phone: 985-702-1220
  • Fax: 985-702-9715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15521R
License Number StateLA

VIII. Authorized Official

Name: DR. MARYELLON ALLEN
Title or Position: MD
Credential: M.D.
Phone: 985-702-1220