Basic Information
| Provider Information | |||||||||
| NPI: | 1043252380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CVT SURGICAL CENTER, AMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | SUITE 1008 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257660416 | ||||||||
| FaxNumber: | 2257699212 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | SUITE 1008 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257660416 | ||||||||
| FaxNumber: | 2257699212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAGGETT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2257660416 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 09015532 | 05 | MS | MEDICAID | 1793426 | 05 | LA | MEDICAID |