Basic Information
| Provider Information | |||||||||
| NPI: | 1255377297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST LOUISIANA RADIOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1813 NORTHPOINTE LN | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712703879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182557591 | ||||||||
| FaxNumber: | 3182557584 | ||||||||
| Practice Location | |||||||||
| Address1: | 1813 NORTHPOINTE LN | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712703879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182557591 | ||||||||
| FaxNumber: | 3182557584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | BRENTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3182834483 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CF8948 | 01 | RAILROAD MEDICARE | OTHER | 137419002 | 05 | AR | MEDICAID | 1949523 | 05 | LA | MEDICAID |