1508858150 NPI number — LYNN B BERNAL-GREEN MD

Table of content: LYNN B BERNAL-GREEN MD (NPI 1508858150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508858150 NPI number — LYNN B BERNAL-GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNAL-GREEN
Provider First Name:
LYNN
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREEN
Provider Other First Name:
LYNN
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508858150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 62755
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70162-2755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-785-2221
Provider Business Mailing Address Fax Number:
985-785-1118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 FOUCHER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-897-8418
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2005

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: 207ZP0102X , with the licence number:  L015762 , 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: 1924521 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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