Healthcare Provider Details

I. General information

NPI: 1932662616
Provider Name (Legal Business Name): PHYSICIAN GROUP OF LOUISIANA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
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 24573
BELFAST ME
04915-4496
US

V. Phone/Fax

Practice location:
  • Phone: 318-329-4200
  • Fax: 318-329-4710
Mailing address:
  • Phone: 855-660-0300
  • Fax:

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: JONATHAN A DEMKE
Title or Position: CEO
Credential:
Phone: 615-467-1072