Basic Information
| Provider Information | |||||||||
| NPI: | 1164697983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BATON ROUGE ORTHOPAEDIC CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION ORTHOPAEDIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8080 BLUEBONNET BLVD | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708107827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259242424 | ||||||||
| FaxNumber: | 2254087984 | ||||||||
| Practice Location | |||||||||
| Address1: | 1023 W HIGHWAY 30 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257432366 | ||||||||
| FaxNumber: | 2257432369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | BOWLIN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9859740422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BATON ROUGE ORTHOPAEDIC CLINIC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1793418 | 05 | LA | MEDICAID |