Nwabueze Nnamdi Inc
Organization Active NPI Internal Medicine Physician · Jackson, LA
NPI 1114047735 · NPPES record last updated Jul 6, 2015
Key facts
- NPI
- 1114047735
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- L12712R (LA)
- Legal business name
- NWABUEZE NNAMDI INC
- Practice address
- 3050 Charles Dr
Jackson, LA 70748-6135 - Phone
- (225) 634-3517
- Fax
- (225) 635-5057
- NPI assigned
- Mar 29, 2007
- Organization subpart
- No
Authorized official
- Name
- Dr. Stacie N Nwabueze, PH.D
- Title
- Administrator
- Phone
- (225) 634-3517
Practitioners 2
-
Nnamdi Andrew Nwabueze, M.D.
-
Stacie Nwabueze, PHD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 19D0961333 | East Feliciana Primary Care Clinic | Provider-performed microscopy | Oct 15, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in LA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041020000724 | LA | Part B Supplier - Clinic/Group Practice | 8426019712 |
Receives reassigned benefits from 1 practitioner Practice locations: Jackson, LA |
National Provider Directory
Locations
3050 Charles Dr
#1
Jackson, LA 70748
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | L12712R | LA | Yes |
| General Practice Physician |
208D00000X | L12712R | LA |
Addresses
Primary practice location
3050 Charles Dr
Jackson, LA 70748-6135
Mailing address
3050 Charles Dr
Jackson, LA 70748-6135
Phone (225) 634-3517
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1552232 | Medicaid | LA | |
| 2330241 | Medicaid | LA |
Other names
- EAST FELICIANA PRIMARY CARE CLINIC
Other providers in Jackson, LA
- Jose Kiamco Mendoza Jr.
- Jamie Miller
- Schicka Mitchell
- Monroe and Maggie House, LLC
- Darlene Ngo
- Nnamdi Andrew Nwabueze
- Stacie Nwabueze
- Gabriel I Onor Sr.
- Robert William Papcsy III
- Waylon Morris Parker
All providers in Jackson, LA · Internal Medicine Physician in Louisiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 6, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.