MEDICARE: LEESVILLE CARDIOVASCULAR CENTER INC

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	207RC0000X	Cardiovascular Disease Physician	11538R	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DD4050	OTHER	LA	RAILROAD MEDICARE #

Other Identifiers

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

General Provider Information

NPI Number	:	1194794867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEESVILLE CARDIOVASCULAR CENTER INC

Provider Business Mailing Address
First Line	:	1101A PORT ARTHUR TER
Second Line	:
City	:	LEESVILLE
State	:	LA
Zip	:	71446-4635
Country	:	US
Telephone Number	:	337-392-2211
Fax Number	:	337-392-2210

Provider Business Practice Location Address
First Line	:	1101A PORT ARTHUR TER
Second Line	:
City	:	LEESVILLE
State	:	LA
Zip	:	71446-4635
Country	:	US
Telephone Number	:	337-392-2211
Fax Number	:	337-392-2210

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. GEETHA M MATHEW
Credential	:
Telephone Number	:	337-392-2211

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	03/16/2010

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