MEDICARE: MRS. MARY LOUISE TALBERT

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	174400000X	Specialist	2921-302-571	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2921-302-571	OTHER	LA	NATIONAL CERT. COD. SPEC.

General Provider Information

NPI Number	:	1477585040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY LOUISE TALBERT

Provider Business Mailing Address
First Line	:	PO BOX 580
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70602-0580
Country	:	US
Telephone Number	:	337-439-2119
Fax Number	:	337-439-2120

Provider Business Practice Location Address
First Line	:	1011 LAKE SHORE DR
Second Line	:	STE. 522
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-9412
Country	:	US
Telephone Number	:	337-439-2119
Fax Number	:	337-439-2120

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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