Provider Demographics
NPI:1164443826
Name:FAMILY PRACTICE ASSOCIATES OF
Entity type:Organization
Organization Name:FAMILY PRACTICE ASSOCIATES OF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAMIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-797-6661
Mailing Address - Street 1:8383 MILLICENT WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-5207
Mailing Address - Country:US
Mailing Address - Phone:318-797-6661
Mailing Address - Fax:318-795-8512
Practice Address - Street 1:8383 MILLICENT WAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-5207
Practice Address - Country:US
Practice Address - Phone:318-797-6661
Practice Address - Fax:318-795-8512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACI5350OtherRR MCR
LA1941999Medicaid
LA56735Medicare ID - Type UnspecifiedGROUP NUMBER