Healthcare Provider Details

I. General information

NPI: 1124385760
Provider Name (Legal Business Name): IKEMD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2547 PALMYRA ST SUITE 101
NEW ORLEANS LA
70119-6427
US

IV. Provider business mailing address

2547 PALMYRA ST SUITE 101
NEW ORLEANS LA
70119-6427
US

V. Phone/Fax

Practice location:
  • Phone: 504-754-2388
  • Fax: 504-754-7669
Mailing address:
  • Phone: 504-754-2388
  • Fax: 504-754-7669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMD.205087
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD.205087
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberMD.205087
License Number StateLA

VIII. Authorized Official

Name: DR. PAUL A.R. IKEMIRE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 504-717-3050