Basic Information
| Provider Information | |||||||||
| NPI: | 1407858566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CENTER FOR PEDIATRIC AND ADOLESCENT MEDICINE,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 N ACADIA RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854483700 | ||||||||
| FaxNumber: | 9854483900 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 N ACADIA RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854483700 | ||||||||
| FaxNumber: | 9854483900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | TOUPS | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9854483700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1948446 | 05 | LA | MEDICAID |