1548668452 NPI number — GRADY ENDOCRINOLOGY CENTER LLC

Table of content: (NPI 1548668452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548668452 NPI number — GRADY ENDOCRINOLOGY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRADY ENDOCRINOLOGY CENTER 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:
1548668452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10512 S GLENSTONE PL
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70810-2966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-505-5532
Provider Business Mailing Address Fax Number:
225-926-9674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10512 S GLENSTONE PL
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70810-2966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-505-5532
Provider Business Practice Location Address Fax Number:
225-926-9674
Provider Enumeration Date:
12/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MATRISCIANO
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
GRADY
Authorized Official Title or Position:
MANAGING MEMBER / OWNER
Authorized Official Telephone Number:
516-380-1490

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  MD202783 , 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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