Basic Information
| Provider Information | |||||||||
| NPI: | 1215053533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEPHENS MEDICAL ENTERPRISES, INCORPORATION | ||||||||
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| OtherOrganizationName: | STEPHENS MEDICAL ENTERPRISES, INCORPORATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66239 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708966239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252676509 | ||||||||
| FaxNumber: | 2252656522 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 CONVENTION ST | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252676509 | ||||||||
| FaxNumber: | 2252656522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | COE | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | AMELIA | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2252676509 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 015345 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1336106 | 05 | LA | MEDICAID |