1972513364 NPI number — MR. DALE BEAIRD GLOVER PA-C

Table of content: MR. DALE BEAIRD GLOVER PA-C (NPI 1972513364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972513364 NPI number — MR. DALE BEAIRD GLOVER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLOVER
Provider First Name:
DALE
Provider Middle Name:
BEAIRD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1972513364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CRESCENT CITY PHYSICIANS, INC.
Provider Second Line Business Mailing Address:
3600 PRYTANIA ST., STE. 35
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70115-3678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-897-7197
Provider Business Mailing Address Fax Number:
504-249-5311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 FOUCHER ST FL 5
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:
70115-3515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-897-7999
Provider Business Practice Location Address Fax Number:
504-897-7676
Provider Enumeration Date:
08/08/2006

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: 363A00000X , with the licence number:  PA04743 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 200155 , 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: 2131991 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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