Basic Information
| Provider Information | |||||||||
| NPI: | 1508175704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LCMS PULMONARY ASSOCIATES OF SOUTHWEST LOUISIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122309, DEPT 2309 DEPT 2309 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 2770 3RD AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706010404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942750 | ||||||||
| FaxNumber: | 3374942760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON-HATCHER | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3374942094 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE CHARLES MEDICAL SERVICES, INC | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 2128353 | 05 | LA | MEDICAID |