Basic Information
| Provider Information | |||||||||
| NPI: | 1770587248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATERNAL FETAL MEDICINE OF ACADIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51742 | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375939099 | ||||||||
| FaxNumber: | 3379484392 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375939099 | ||||||||
| FaxNumber: | 3379484392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2005 | ||||||||
| LastUpdateDate: | 10/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | DIBBS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3379421151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 11220R | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1447757 | 05 | LA | MEDICAID |