1063557551 NPI number — DR. EDWARD G GILCREASE

Table of content: DR. EDWARD G GILCREASE (NPI 1063557551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063557551 NPI number — DR. EDWARD G GILCREASE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILCREASE
Provider First Name:
EDWARD
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063557551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 N 7TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71291-4334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-330-9070
Provider Business Mailing Address Fax Number:
318-387-4343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 S VIENNA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-5832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-255-9433
Provider Business Practice Location Address Fax Number:
318-255-2425
Provider Enumeration Date:
02/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1398-528T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1475815 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".