Healthcare Provider Details

I. General information

NPI: 1568764124
Provider Name (Legal Business Name): NORTHLAKE CARDIOLOGY DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 ROBERT BLVD SUITE 340
SLIDELL LA
70458-2004
US

IV. Provider business mailing address

1150 ROBERT BLVD SUITE 340
SLIDELL LA
70458-2004
US

V. Phone/Fax

Practice location:
  • Phone: 985-649-2883
  • Fax: 985-649-2953
Mailing address:
  • Phone: 985-649-2883
  • Fax: 985-649-2953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number05592R
License Number StateLA

VIII. Authorized Official

Name: DR. MADAELIL G. THOMAS
Title or Position: PRESIDENT
Credential: MD
Phone: 985-649-2883