Basic Information
| Provider Information | |||||||||
| NPI: | 1740466440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCP MEDICAL MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 FOURPARK RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705072481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378966400 | ||||||||
| FaxNumber: | 3378966441 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 FOURPARK RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705072481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378966400 | ||||||||
| FaxNumber: | 3378966441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2008 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | PHIPPS | ||||||||
| AuthorizedOfficialFirstName: | GROVER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3378966400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 026036 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1447692 | 05 | LA | MEDICAID |