Basic Information
| Provider Information | |||||||||
| NPI: | 1932448354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPERIAL CALCASIEU MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
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| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128284 | ||||||||
| FaxNumber: | 3373126708 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | SULPHUR | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706633424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375276385 | ||||||||
| FaxNumber: | 3375273527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | HICKINGBOTTOM | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3374338400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.