Basic Information
| Provider Information | |||||||||
| NPI: | 1437775459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPACT PHYSICIAN GROUP, LOUISIANA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 EASTBROOK BND STE 218 | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302691546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604078009 | ||||||||
| FaxNumber: | 2604078009 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 RUE DE JARDIN STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706054050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604078009 | ||||||||
| FaxNumber: | 2604078009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2020 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2604078009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.