Impact Physician Group, Pediatrics LLC

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

Legal business name

IMPACT PHYSICIAN GROUP, PEDIATRICS LLC

Practice address

2720 Rue de Jardin Ste 100
Lake Charles, LA 70605-4050

Phone

(260) 407-8009

Fax

(260) 407-8009

NPI assigned

Jun 25, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Paul Miller

Title

Ceo

Phone

(678) 967-5599

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1593043200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1647302400000",
    "number": "1689290603",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 EASTBROOK BND STE 218",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302691546",
            "telephone_number": "678-967-5599"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2720 RUE DE JARDIN STE 100",
            "city": "LAKE CHARLES",
            "state": "LA",
            "postal_code": "706054050",
            "telephone_number": "260-407-8009",
            "fax_number": "260-407-8009"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT PHYSICIAN GROUP, PEDIATRICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-06-25",
        "last_updated": "2022-03-15",
        "certification_date": "2022-03-15",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "678-967-5599"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Susan Bourgeois Ieyoub, MD
• William L. Iglinsky, M.D.
• Iles Medical Testing,LLC
• Impact Health & Wellness Lab, LLC
• Impact Physician Group, Louisiana LLC
• Imperial Calcasieu Human Services Authority (LCBHC Childrens Outreach Services)
• Imperial Calcasieu Human Services Authority (ImCal Primary Care)
• Imperial Calcasieu Human Services Authority (ImCal BH Lake Charles)
• Imperial Calcasieu Surgical Center LLC (Christus Imperial Calcasieu Surgical Center)
• Imperial Excellence Transportation/Taxi, LLC

• Pediatrics Physician in Lake Charles, LA
• Providers in Lake Charles, LA by specialty
• Pediatrics Physician in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.