Provider Demographics
NPI:1104844455
Name:GIARRUSSO, BRAD C (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:C
Last Name:GIARRUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0177
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:6516 E MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-4348
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-774-5432
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026403208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1065421Medicaid
LA4J606C822Medicare PIN
LA4J606CN822Medicare PIN
LA4J606Medicare PIN
LAI30374Medicare UPIN