Basic Information
| Provider Information | |||||||||
| NPI: | 1386777597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIDNEY H RAYMOND LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4315 HOUMA BLVD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700062940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048895250 | ||||||||
| FaxNumber: | 5048895288 | ||||||||
| Practice Location | |||||||||
| Address1: | 4315 HOUMA BLVD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700062940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048895250 | ||||||||
| FaxNumber: | 5048895288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 11/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | RAYMOND | ||||||||
| AuthorizedOfficialFirstName: | SIDNEY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5048895250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 023838 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1485501 | 05 | LA | MEDICAID |