MEDICARE: MARYANNE L COLBURN R.T.

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	247100000X	Radiologic Technologist	1951	LA

General Provider Information

NPI Number	:	1831353895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYANNE L COLBURN R.T.

Provider Business Mailing Address
First Line	:	721 PARK RIDGE DR
Second Line	:
City	:	RIVER RIDGE
State	:	LA
Zip	:	70123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	721 PARK RIDGE DR
Second Line	:
City	:	RIVER RIDGE
State	:	LA
Zip	:	70123-1182
Country	:	US
Telephone Number	:	504-738-5273
Fax Number	:

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

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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