Healthcare Provider Details

I. General information

NPI: 1679569560
Provider Name (Legal Business Name): PEDIATRIC CLINIC OF ST MARY PARISH APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 DAVID DR
MORGAN CITY LA
70380-1300
US

IV. Provider business mailing address

1055 DAVID DR
MORGAN CITY LA
70380-1300
US

V. Phone/Fax

Practice location:
  • Phone: 985-384-2430
  • Fax: 985-384-2473
Mailing address:
  • Phone: 985-384-2430
  • Fax: 985-384-2473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY THORGUSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 985-384-2430