# J H FAIRBANKS MD PLLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** J H FAIRBANKS MD PLLC
- **Other names:** Riverpark Sports Medicine and Physical Therapy
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1336209550
- **Legal business name:** J H FAIRBANKS MD PLLC
- **Authorized official:** ANGEL NICOLE NUGENT (MANAGER)
- **Authorized official phone:** (318) 336-2212

## Contact information

- **Practice address:** 107 FRONT ST, SUITE 230, VIDALIA, LA 39120
- **Practice address phone:** (318) 336-2212
- **Practice address fax:** (318) 336-6067
- **Mailing address:** 107 FRONT ST, SUITE 230, VIDALIA, LA 39120
- **Mailing address phone:** (318) 336-2212
- **Mailing address fax:** (318) 336-6067

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207X00000X | Orthopaedic Surgery Physician | 15703 | MS | — |
| 207X00000X | Orthopaedic Surgery Physician | MD017268 | LA | Yes |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | MD017268 | LA | — |

## Other

- **Enumeration date:** 12/11/2006
- **Last updated:** 07/03/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00119142 | — | MS |
| 05 | — | 1384101 | — | LA |