MEDICARE: PEDIATRIC GROUP OF ACADIANA, 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	174400000X	Specialist	10447R	LA
2	261QR1300X	Rural Health Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	193885	OTHER	LA	MEDICARE RURAL HEALTH ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922283225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC GROUP OF ACADIANA, LLC

Provider Business Mailing Address
First Line	:	401 YOUNGSVILLE HWY STE 100
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-5173
Country	:	US
Telephone Number	:	337-330-0031
Fax Number	:

Provider Business Practice Location Address
First Line	:	1119 N MAIN ST
Second Line	:
City	:	SAINT MARTINVILLE
State	:	LA
Zip	:	70582-3513
Country	:	US
Telephone Number	:	337-394-7774
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	ALEC MOYER
Credential	:
Telephone Number	:	337-256-5111

Provider Enumeration Date	:	01/04/2008
Last Update Date	:	12/16/2019

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Directions to “PEDIATRIC GROUP OF ACADIANA, LLC ” Practice Location

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