Basic Information
| Provider Information | |||||||||
| NPI: | 1215380506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER PEDIATRICS OF ACADIANA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 HOSPITAL DR | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372371252 | ||||||||
| FaxNumber: | 9856356948 | ||||||||
| Practice Location | |||||||||
| Address1: | 1512 CHEMIN METAIRIE RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | YOUNGSVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705925382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372371252 | ||||||||
| FaxNumber: | 9856356948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | GAST | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9856356943 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.205011 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.