Provider Demographics
NPI:1124042585
Name:CHARLES R. BYRD MD A PROFESSIONAL
Entity Type:Organization
Organization Name:CHARLES R. BYRD MD A PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-221-4755
Mailing Address - Street 1:2751 ALBERT L BICKNELL DR
Mailing Address - Street 2:STE 3-D
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-221-4755
Mailing Address - Fax:318-424-3642
Practice Address - Street 1:2751 ALBERT L BICKNELL DR
Practice Address - Street 2:STE 3-D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-221-4755
Practice Address - Fax:318-424-3642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449768Medicaid
LA1449768Medicaid
LA50762CH59Medicare PIN