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General NPI Number Information
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NPI Number | 1437553617
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Entity Type | Organization
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Legal Business Name | MANDEVILLE PRIVATE PHYSICIAN GROUP
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Dates
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Enumeration Date | 10/16/2014
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Last Update Date | 05/01/2017
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Provider Practice Location Address
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Address Line | 141 LAKEVIEW CIR
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City | COVINGTON
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State | LA
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Zip | 70433-7513
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Country | US
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Telephone | 985-630-9618
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Fax | 985-231-7010
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Provider Business Mailing Address
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Address Line | PO BOX 335
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City | MANDEVILLE
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State | LA
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Zip | 70470-0335
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Country | US
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Telephone | 985-630-9618
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Fax | 985-231-7010
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. RICHARD MICHAEL JEANSONNE JR.
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Credential | MD
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Telephone | 985-630-9618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 025708
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License Number State | LA
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