Healthcare Provider Details

I. General information

NPI: 1316188998
Provider Name (Legal Business Name): PHYSICIAN GROUP OF LOUISIANA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MCMILLAN RD
WEST MONROE LA
71291-5327
US

IV. Provider business mailing address

PO BOX 281796
ATLANTA GA
30384-1796
US

V. Phone/Fax

Practice location:
  • Phone: 318-329-4200
  • Fax: 318-329-4710
Mailing address:
  • Phone: 866-243-7107
  • Fax: 314-432-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY KOCH
Title or Position: CFO
Credential:
Phone: 617-562-7070