MEDICARE: YOUNGSVILLE MEDICAL CLINIC

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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H3327	OTHER	LA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1689696270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUNGSVILLE MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	811 ALBERTSON PKWY STE F
Second Line	:
City	:	BROUSSARD
State	:	LA
Zip	:	70518-5256
Country	:	US
Telephone Number	:	337-837-3615
Fax Number	:	337-839-8097

Provider Business Practice Location Address
First Line	:	811 ALBERTSON PKWY STE F
Second Line	:
City	:	BROUSSARD
State	:	LA
Zip	:	70518-5256
Country	:	US
Telephone Number	:	337-837-3615
Fax Number	:	337-839-8097

Authorized Official
Title or Position	:	MD
Name	:	JORGE RAFAEL BELGODERE-BONILLA
Credential	:
Telephone Number	:	337-837-3615

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	09/12/2022

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Directions to “YOUNGSVILLE MEDICAL CLINIC ” Practice Location

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