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General NPI Number Information
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NPI Number | 1528108503
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Entity Type | Organization
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Legal Business Name | ORTHO CLINIC - PROFESSIONAL MEDICAL
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 01/16/2013
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Provider Practice Location Address
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Address Line | 516 JEFFERSON TERRRACE BLVD SUITE 100
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City | NEW IBERIA
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State | LA
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Zip | 70560-4948
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Country | US
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Telephone | 337-364-5310
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Fax | 337-364-5313
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Provider Business Mailing Address
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Address Line | 516 JEFFERSON TER SUITE 100
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City | NEW IBERIA
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State | LA
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Zip | 70560-4980
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Country | US
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Telephone | 337-364-5310
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Fax | 337-364-5313
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. EDWARD J LISECKI
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Credential | M.D.,
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Telephone | 337-364-5310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 26008
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License Number State | LA
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