Basic Information
Provider Information
NPI: 1457684995
EntityType: 2
ReplacementNPI:  
OrganizationName: THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: THIBODAUX REGIONAL NETWORK DEVELOPMENT CORPORATION - MATERNAL FETAL
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 5478
Address2:  
City: THIBODAUX
State: LA
PostalCode: 703025478
CountryCode: US
TelephoneNumber: 9854934544
FaxNumber: 9854492535
Practice Location
Address1: 602 N ACADIA RD
Address2:  
City: THIBODAUX
State: LA
PostalCode: 703014847
CountryCode: US
TelephoneNumber: 9854934544
FaxNumber: 9855449253
Other Information
ProviderEnumerationDate: 09/16/2009
LastUpdateDate: 12/07/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GAUBERT
AuthorizedOfficialFirstName: STEVE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: AGENT
AuthorizedOfficialTelephone: 9854934721
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207VM0101X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine

ID Information
IDTypeStateIssuerDescription
180441005LA MEDICAID


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