MEDICARE: M A CULASSO, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	013032	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083617237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M A CULASSO, LLC

Provider Business Mailing Address
First Line	:	PO BOX 729
Second Line	:
City	:	SLIDELL
State	:	LA
Zip	:	70459-0729
Country	:	US
Telephone Number	:	985-646-0945
Fax Number	:	985-643-8510

Provider Business Practice Location Address
First Line	:	1520 GAUSE BLVD
Second Line	:
City	:	SLIDELL
State	:	LA
Zip	:	70458-2208
Country	:	US
Telephone Number	:	985-649-0945
Fax Number	:	985-643-8510

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	MR. MIGUEL A CULASSO
Credential	:	MD
Telephone Number	:	985-646-0945

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	04/05/2011

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Directions to “M A CULASSO, LLC ” Practice Location

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