MEDICARE: COLUMBIA HEALTHCARE SYSTEMS OF LA, INC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5CQ93	OTHER	LA	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1972559888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA HEALTHCARE SYSTEMS OF LA, INC

Provider Business Mailing Address
First Line	:	3418 MEDICAL PARK DR
Second Line	:	STE 3
City	:	MONROE
State	:	LA
Zip	:	71203-2376
Country	:	US
Telephone Number	:	318-325-5661
Fax Number	:

Provider Business Practice Location Address
First Line	:	3418 MEDICAL PARK DR
Second Line	:	STE 3
City	:	MONROE
State	:	LA
Zip	:	71203-2376
Country	:	US
Telephone Number	:	318-325-5661
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	ROBERT R LAGESSE
Credential	:
Telephone Number	:	318-325-5661

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	09/20/2007

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