1821014473 NPI number — MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC-METAIRIE

Table of content: (NPI 1821014473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821014473 NPI number — MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC-METAIRIE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC-METAIRIE
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:
6
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:
1821014473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 121
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARRERO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70073-0121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 KINGMAN ST
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70006-4236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-885-3345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLDEN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF MANAGER OF LLC
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1182915 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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