Basic Information
| Provider Information | |||||||||
| NPI: | 1184648651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BATON ROUGE GENERAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8490 PICARDY AVE | ||||||||
| Address2: | BLDG 200 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252371754 | ||||||||
| FaxNumber: | 2252371722 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 NORTH BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253816620 | ||||||||
| FaxNumber: | 2253816629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | KENDALL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2252371645 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1943053 | 05 | LA | MEDICAID | CC5865 | 01 | LA | RAILROAD MEDICARE | OTHER |