Healthcare Provider Details

I. General information

NPI: 1598311029
Provider Name (Legal Business Name): SOUTHERN LOUISIANA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GAUSE BLVD W STE A
SLIDELL LA
70460-4130
US

IV. Provider business mailing address

PO BOX 7462
SLIDELL LA
70469-7462
US

V. Phone/Fax

Practice location:
  • Phone: 985-643-4575
  • Fax: 833-222-4520
Mailing address:
  • Phone: 985-643-4575
  • Fax: 833-222-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAREN DRAKE
Title or Position: GENERAL MANAGER
Credential:
Phone: 504-229-7451