MEDICARE: WEST JEFFERSON SURGERY CENTER, 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	261QA1903X	Ambulatory Surgical Clinic/Center	115	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
2	115	OTHER	LA	LIC NUMBER

General Provider Information

NPI Number	:	1487657359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST JEFFERSON SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	1111 MEDICAL CENTER BLVD
Second Line	:	SUITE 105 NORTH
City	:	MARRERO
State	:	LA
Zip	:	70072
Country	:	US
Telephone Number	:	504-349-2332
Fax Number	:	504-349-2359

Provider Business Practice Location Address
First Line	:	1111 MEDICAL CENTER BLVD
Second Line	:	STE 105N
City	:	MARRERO
State	:	LA
Zip	:	70072-3152
Country	:	US
Telephone Number	:	504-349-2332
Fax Number	:	504-349-2359

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MR. MARK JUNEAU
Credential	:	M.D.
Telephone Number	:	504-349-2332

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/22/2020

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