=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326590530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL CONSULTANTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2016
-----------------------------------------------------
Last Update Date | 11/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3213 17TH ST
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-997-0196
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2615 GAULT AVE N
-----------------------------------------------------
City | FORT PAYNE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35967-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT RAYMOND
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 256-997-0196
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | MD08891R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------