1467741785 NPI number — GULF SOUTH PHYSICIANS GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467741785 NPI number — GULF SOUTH PHYSICIANS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF SOUTH PHYSICIANS GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1467741785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 HOUMA BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70006-4165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-309-8135
Provider Business Mailing Address Fax Number:
504-309-8156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 HOUMA BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70006-4165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-309-8135
Provider Business Practice Location Address Fax Number:
504-309-8156
Provider Enumeration Date:
04/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CEASAR
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
504-309-8135

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD025275 , 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)





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