Organization
J H FAIRBANKS MD PLLC
Active
Parent organization
J H FAIRBANKS MD PLLC
Other names
Riverpark Sports Medicine and Physical Therapy
Organization subpart
Yes
Provider details
NPI number
Legal business name
J H FAIRBANKS MD PLLC
Authorized official
ANGEL NICOLE NUGENT (MANAGER)
(318) 336-2212
Entity
Organization
Contact information
Practice address
107 FRONT ST, SUITE 230, VIDALIA, LA 39120
(318) 336-2212
(318) 336-6067
Mailing address
107 FRONT ST, SUITE 230, VIDALIA, LA 39120
(318) 336-2212
(318) 336-6067
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
15703
MS
207X00000X
Orthopaedic Surgery Physician
Primary
MD017268
LA
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
MD017268
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00119142
—
MS
05
—
1384101
—
LA
Enumeration date
12/11/2006
Last updated
07/03/2023
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