Basic Information
| Provider Information | |||||||||
| NPI: | 1649408832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAFAYETTE GENERAL MEDICAL CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1214 COOLIDGE BLVD | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898978 | ||||||||
| FaxNumber: | 3372898970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1214 COOLIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898978 | ||||||||
| FaxNumber: | 3372898970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | MATTKE | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3372898678 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1816451 | 05 | LA | MEDICAID |