Basic Information
| Provider Information | |||||||||
| NPI: | 1780075499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN LOUISIANA UNIVERISITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SLU SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650850 | ||||||||
| Address2: | DEPT. 1011 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 GALLOWAY DR | ||||||||
| Address2: | DUGAS CENTER | ||||||||
| City: | HAMMOND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704020001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9855495133 | ||||||||
| FaxNumber: | 9723673451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | IRWIN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASST. DIRECTOR FOR SPORTS MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 9855495133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.