1548457559 NPI number — GORDON ELLIS WHITE MD,LLC

Table of content: (NPI 1548457559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548457559 NPI number — GORDON ELLIS WHITE MD,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDON ELLIS WHITE MD,LLC
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:
1548457559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 4TH ST
Provider Second Line Business Mailing Address:
MEDICAL PLAZA, STE. 2E
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71301-8421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-443-9400
Provider Business Mailing Address Fax Number:
318-442-9406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 4TH ST
Provider Second Line Business Practice Location Address:
MEDICAL PLAZA, STE. 2E
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71301-8421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-443-9400
Provider Business Practice Location Address Fax Number:
318-442-9406
Provider Enumeration Date:
10/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAN
Authorized Official Telephone Number:
318-443-9400

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  025398 , 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: 1423688 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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