Basic Information
| Provider Information | |||||||||
| NPI: | 1295816635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE & PEDIATRIC GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6516 EAST MYRTLE STREET | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257747320 | ||||||||
| FaxNumber: | 2257745432 | ||||||||
| Practice Location | |||||||||
| Address1: | 6516 EAST MYRTLE STREET | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257747320 | ||||||||
| FaxNumber: | 2257745432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SPEEG | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | WARNER | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2257747320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1443093 | 05 | LA | MEDICAID |