Provider Demographics
NPI:1174624712
Name:JON V. SCHELLACK, M.D. (A PROFESSIONAL MEDICAL CORPORATION)
Entity type:Organization
Organization Name:JON V. SCHELLACK, M.D. (A PROFESSIONAL MEDICAL CORPORATION)
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:V
Authorized Official - Last Name:SCHELLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-767-5479
Mailing Address - Street 1:5425 BRITTANY DR # B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9144
Mailing Address - Country:US
Mailing Address - Phone:225-767-5479
Mailing Address - Fax:225-767-5147
Practice Address - Street 1:5425 BRITTANY DR # B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9144
Practice Address - Country:US
Practice Address - Phone:225-767-5479
Practice Address - Fax:225-767-5147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1446564Medicaid
LA5CC83Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER