=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245272541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 06/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 CHEROKEE ROSE LN
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-7195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-871-1721
-----------------------------------------------------
Fax | 985-871-4049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 848778
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02284-8778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-871-1721
-----------------------------------------------------
Fax | 985-893-6908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | HAZEL BRAUEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-871-1721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------