Provider Demographics
NPI:1548440811
Name:ALL AGE MEDICAL P.C., INC.
Entity type:Organization
Organization Name:ALL AGE MEDICAL P.C., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:NATALIE
Authorized Official - Last Name:BLAKE-MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-741-8100
Mailing Address - Street 1:2910 SHED RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3154
Mailing Address - Country:US
Mailing Address - Phone:318-741-8100
Mailing Address - Fax:318-741-5700
Practice Address - Street 1:2910 SHED RD
Practice Address - Street 2:SUITE B
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3154
Practice Address - Country:US
Practice Address - Phone:318-741-8100
Practice Address - Fax:318-741-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14851R261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1150185Medicaid
LA5CF72OtherGROUP PTAN # (CMS)
LA1150185Medicaid
LAH84202Medicare UPIN