Healthcare Provider Details

I. General information

NPI: 1801195300
Provider Name (Legal Business Name): SURGEONCARE PHYSICIANS OF LOUISIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 N PINE RD
OLLA LA
71465
US

IV. Provider business mailing address

PO BOX 4207
MACON GA
31208-4207
US

V. Phone/Fax

Practice location:
  • Phone: 318-495-0760
  • Fax: 318-495-0749
Mailing address:
  • Phone: 318-495-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY ROBERTSON
Title or Position: CFO
Credential:
Phone: 336-852-6525