Basic Information
| Provider Information | |||||||||
| NPI: | 1649422726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADIANA RADIOLOGY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4628 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392964628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019827878 | ||||||||
| FaxNumber: | 6019827909 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 AMBASSADOR CAFFERY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374702180 | ||||||||
| FaxNumber: | 3374702677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | WOJAK | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3374702180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1796727 | 05 | LA | MEDICAID |