Basic Information
| Provider Information | |||||||||
| NPI: | 1114189016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY CONSULTANTS OF LOUISIANA A PROFESSIONAL MEDICAL CORPORATIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7010 | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700107010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044544120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FRANKLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704383688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044544120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5044544120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1794457 | 05 | LA | MEDICAID |