Healthcare Provider Details

I. General information

NPI: 1023062718
Provider Name (Legal Business Name): FONTENOT & MCINTOSH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 GLENWOOD DR
WEST MONROE LA
71291-5539
US

IV. Provider business mailing address

PO BOX 2850
RUSTON LA
71273-2850
US

V. Phone/Fax

Practice location:
  • Phone: 318-322-1339
  • Fax:
Mailing address:
  • Phone: 800-903-4859
  • Fax: 601-936-0686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: H JERREL FONTENOT
Title or Position: PRESIDENT
Credential: M.D., PHD.
Phone: 318-322-1339