Provider Demographics
NPI:1831266162
Name:WEST JEFFERSON PHYSICIAN SERVICES
Entity type:Organization
Organization Name:WEST JEFFERSON PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORD.
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:A
Authorized Official - Last Name:GWINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-349-1297
Mailing Address - Street 1:5140 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LAFITTE
Mailing Address - State:LA
Mailing Address - Zip Code:70067-5256
Mailing Address - Country:US
Mailing Address - Phone:504-349-6525
Mailing Address - Fax:504-349-6529
Practice Address - Street 1:5140 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LAFITTE
Practice Address - State:LA
Practice Address - Zip Code:70067-5256
Practice Address - Country:US
Practice Address - Phone:504-349-6525
Practice Address - Fax:504-349-6529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1942545Medicaid
LA5D265Medicare ID - Type Unspecified