Provider Demographics
NPI:1902095987
Name:MAYO MEDICAL CLINIC
Entity Type:Organization
Organization Name:MAYO MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-381-2712
Mailing Address - Street 1:3401 NORTH BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3743
Mailing Address - Country:US
Mailing Address - Phone:225-381-2712
Mailing Address - Fax:
Practice Address - Street 1:3401 NORTH BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3743
Practice Address - Country:US
Practice Address - Phone:225-381-2712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023611261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1576565Medicaid
LA5CR21Medicare PIN
LAI19579Medicare UPIN