Basic Information
| Provider Information | |||||||||
| NPI: | 1275081465 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST JEFFERSON GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EJGH WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 HOUMA BLVD | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700062970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045034000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3726 HOUMA BLVD | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700064116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045036868 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2016 | ||||||||
| LastUpdateDate: | 09/15/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAREMORE | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VP / CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5045036410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST JEFFERSON GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 122 | LA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1474886 | 05 | LA | MEDICAID | 1705055 | 05 | LA | MEDICAID | 1735183 | 05 | LA | MEDICAID |