Basic Information
| Provider Information | |||||||||
| NPI: | 1760861348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKALAK | ||||||||
| FirstName: | MARADITH | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOONEN | ||||||||
| OtherFirstName: | MARADITH | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4740 S I 10 SERVICE RD W STE 200 | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700011244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513158025 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4700 S I 10 SERVICE RD W | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700011210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5047808282 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 328460 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 35.133601 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 390200000X | 35.133601 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.