Basic Information
| Provider Information | |||||||||
| NPI: | 1275830655 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MD2U LOUISIANA LLC | ||||||||
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| OtherOrganizationName: | MD2U THE LEADER IN MEDICAL HOUSE CALLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7219 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402570219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279410 | ||||||||
| FaxNumber: | 5027423767 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 SAINT CHARLES AVE | ||||||||
| Address2: | STE. 2500 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701701000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664603567 | ||||||||
| FaxNumber: | 5027423767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2011 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | LATTA | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CIO | ||||||||
| AuthorizedOfficialTelephone: | 5024161851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MD2U MANAGEMENT LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 19D2045836 | 01 | LA | CLIA - CERTIFICATE OF WAIVER | OTHER |