MEDICARE: EVANGELINE SURGICAL CLINIC 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	174400000X	Specialist	22520	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

General Provider Information

NPI Number	:	1518019892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANGELINE SURGICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	504 JACK MILLER RD STE 6
Second Line	:
City	:	VILLE PLATTE
State	:	LA
Zip	:	70586-5600
Country	:	US
Telephone Number	:	337-363-2050
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 JACK MILLER RD STE 6
Second Line	:
City	:	VILLE PLATTE
State	:	LA
Zip	:	70586-5600
Country	:	US
Telephone Number	:	337-363-2050
Fax Number	:

Authorized Official
Title or Position	:	MANAGER MEMBER
Name	:	CRAIG ROBERT THOMPSON
Credential	:	M.D.
Telephone Number	:	337-363-2050

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	08/22/2020

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