MEDICARE: NORTHEAST LOUISIANA CARDIOVASCULAR

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	207RC0000X	Cardiovascular Disease Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4388289030	OTHER	LA	BLUE CROSS

General Provider Information

NPI Number	:	1982799532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST LOUISIANA CARDIOVASCULAR

Provider Business Mailing Address
First Line	:	2503 BROADMOOR BLVD
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71201-2987
Country	:	US
Telephone Number	:	318-322-7726
Fax Number	:	318-322-2614

Provider Business Practice Location Address
First Line	:	2503 BROADMOOR BLVD
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71201-2987
Country	:	US
Telephone Number	:	318-322-7726
Fax Number	:	318-322-2614

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREGORY C SAMPOGNARO
Credential	:	M.D.
Telephone Number	:	318-322-7726

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	02/23/2012

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