MEDICARE: TRAILLE MEDICAL SPECIALTIES, 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	261QP2300X	Primary Care Clinic/Center	53785	LA

General Provider Information

NPI Number	:	1366816761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAILLE MEDICAL SPECIALTIES, LLC

Provider Business Mailing Address
First Line	:	623 S BURGESS DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70815-5202
Country	:	US
Telephone Number	:	225-678-4471
Fax Number	:	225-364-2062

Provider Business Practice Location Address
First Line	:	606 COLONIAL DR
Second Line	:	SUITE A
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6535
Country	:	US
Telephone Number	:	225-330-4956
Fax Number	:	225-364-2062

Authorized Official
Title or Position	:	CEO
Name	:	MR. JAMES A ROEDEMA
Credential	:
Telephone Number	:	225-678-4471

Provider Enumeration Date	:	11/23/2015
Last Update Date	:	11/23/2015

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