MEDICARE: ORTHO CLINIC - PROFESSIONAL MEDICAL

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	207X00000X	Orthopaedic Surgery Physician	26008	LA

General Provider Information

NPI Number	:	1528108503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHO CLINIC - PROFESSIONAL MEDICAL

Provider Business Mailing Address
First Line	:	516 JEFFERSON TER
Second Line	:	SUITE 100
City	:	NEW IBERIA
State	:	LA
Zip	:	70560-4980
Country	:	US
Telephone Number	:	337-364-5310
Fax Number	:	337-364-5313

Provider Business Practice Location Address
First Line	:	516 JEFFERSON TERRRACE BLVD
Second Line	:	SUITE 100
City	:	NEW IBERIA
State	:	LA
Zip	:	70560-4948
Country	:	US
Telephone Number	:	337-364-5310
Fax Number	:	337-364-5313

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. EDWARD J LISECKI
Credential	:	M.D.,
Telephone Number	:	337-364-5310

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	01/16/2013

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