Basic Information
| Provider Information | |||||||||
| NPI: | 1568910503 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIBODAUX EMERGENCY PHYSICIANS GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720487 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052409381 | ||||||||
| FaxNumber: | 4053419217 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 N ACADIA RD | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854475500 | ||||||||
| FaxNumber: | 9042658181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | PROVOST | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3375340952 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.