Basic Information
| Provider Information | |||||||||
| NPI: | 1710052378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDUBON PEDIATRICS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NONE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 216 MYSTIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703602870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689339 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 216 MYSTIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703602870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689339 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KERLEY | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9856880238 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.024810 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1459313 | 05 | LA | MEDICAID |