MEDICARE: DR. BARRY STEPHEN BORDENAVE M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	13559	LA

General Provider Information

NPI Number	:	1811017882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARRY STEPHEN BORDENAVE M.D.

Provider Business Mailing Address
First Line	:	321 OVERHILL DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-6527
Country	:	US
Telephone Number	:	337-474-8886
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 OVERHILL DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-6527
Country	:	US
Telephone Number	:	337-474-8886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	07/08/2007

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