Healthcare Provider Details

I. General information

NPI: 1891216263
Provider Name (Legal Business Name): ORTHOPAEDIC CLINIC OF MONROE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 01/14/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 COMMERCE ST
RUSTON LA
71270-5845
US

IV. Provider business mailing address

1501 LOUISVILLE AVE
MONROE LA
71201-6025
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-8451
  • Fax: 318-361-2613
Mailing address:
  • Phone: 318-323-8451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN GOLDMAN
Title or Position: ADMINISTRATOR
Credential: CFO
Phone: 318-362-4328