Basic Information
| Provider Information | |||||||||
| NPI: | 1205264868 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL GROUP- ST BERNARD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 789 | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395660789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288180563 | ||||||||
| FaxNumber: | 2288180519 | ||||||||
| Practice Location | |||||||||
| Address1: | 8050 W JUDGE PEREZ DR | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | CHALMETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700431734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048269655 | ||||||||
| FaxNumber: | 5048269656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCDANIEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5045222014 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 331631 | 01 | LA | MEDICARE PTAN | OTHER |