MEDICARE: ORTHOPAEDIC SPORTS SPECIALISTS OF LOUISIANA, 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	207XS0106X	Orthopaedic Hand Surgery Physician
2	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1720752827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDIC SPORTS SPECIALISTS OF LOUISIANA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 28
Second Line	:
City	:	THIBODAUX
State	:	LA
Zip	:	70302-0028
Country	:	US
Telephone Number	:	985-625-2200
Fax Number	:	985-625-2206

Provider Business Practice Location Address
First Line	:	1731 LUTCHER AVE STE 1500
Second Line	:
City	:	LUTCHER
State	:	LA
Zip	:	70071-5151
Country	:	US
Telephone Number	:	985-625-2200
Fax Number	:	985-625-2206

Authorized Official
Title or Position	:	OWNER
Name	:	JASON A. HIGGINS
Credential	:	MD
Telephone Number	:	985-625-2200

Provider Enumeration Date	:	08/03/2021
Last Update Date	:	08/03/2021

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