Provider Demographics
NPI:1902131667
Name:FERTILE CRESCENT PEDIATRICS, LLC
Entity Type:Organization
Organization Name:FERTILE CRESCENT PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESPINASSE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:225-924-7343
Mailing Address - Street 1:730 COLONIAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6536
Mailing Address - Country:US
Mailing Address - Phone:225-924-7343
Mailing Address - Fax:225-924-7347
Practice Address - Street 1:730 COLONIAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6536
Practice Address - Country:US
Practice Address - Phone:225-924-7343
Practice Address - Fax:225-924-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023350261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490903Medicaid
LA1490903Medicaid