Healthcare Provider Details

I. General information

NPI: 1568910503
Provider Name (Legal Business Name): THIBODAUX EMERGENCY PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N ACADIA RD
THIBODAUX LA
70301-4823
US

IV. Provider business mailing address

PO BOX 720487
NORMAN OK
73070-4358
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-5500
  • Fax: 904-265-8181
Mailing address:
  • Phone: 405-240-9381
  • Fax: 405-341-9217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY D. PROVOST
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 337-534-0952