Basic Information
Provider Information | |||||||||
NPI: | 1659764967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CALCASIEU CAMERON HOSPITAL MEDICINE GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 721191 | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730704908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052409381 | ||||||||
FaxNumber: | 4053419217 | ||||||||
Practice Location | |||||||||
Address1: | 701 CYPRESS ST | ||||||||
Address2: |   | ||||||||
City: | SULPHUR | ||||||||
State: | LA | ||||||||
PostalCode: | 706635053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3375277034 | ||||||||
FaxNumber: | 3375340953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2015 | ||||||||
LastUpdateDate: | 03/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PROVOST | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 3375340952 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | DV5356 | 01 | LA | RR MEDICARE | OTHER | 2385887 | 05 | LA |   | MEDICAID |