Provider Demographics
NPI:1053589697
Name:BIENVILLE MEDICAL CENTER PHYSICIAN GROUP
Entity type:Organization
Organization Name:BIENVILLE MEDICAL CENTER PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDELON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-221-3202
Mailing Address - Street 1:1175 PINE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ARCADIA
Mailing Address - State:LA
Mailing Address - Zip Code:71001-3113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 PINE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-3113
Practice Address - Country:US
Practice Address - Phone:318-629-5340
Practice Address - Fax:318-221-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1707023Medicaid
LA1707023Medicaid