MEDICARE: NORTHSHORE FAMILY MEDICINE, 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

General Provider Information

NPI Number	:	1134194095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSHORE FAMILY MEDICINE, LLC

Provider Business Mailing Address
First Line	:	1417 STILLWATER DR
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-7452
Country	:	US
Telephone Number	:	985-875-9166
Fax Number	:

Provider Business Practice Location Address
First Line	:	1119 S TYLER ST
Second Line	:
City	:	COVINGTON
State	:	LA
Zip	:	70433-2327
Country	:	US
Telephone Number	:	985-875-9166
Fax Number	:	985-875-9170

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES BALETTE
Credential	:	M.D.
Telephone Number	:	985-875-9166

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	10/29/2009

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