Provider Demographics
NPI:1215185855
Name:GERIATRIC MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GERIATRIC MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-212-3830
Mailing Address - Street 1:1300 GRIMMETT DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6502
Mailing Address - Country:US
Mailing Address - Phone:318-212-3830
Mailing Address - Fax:318-212-3835
Practice Address - Street 1:7813 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5505
Practice Address - Country:US
Practice Address - Phone:318-212-3830
Practice Address - Fax:318-212-3835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL010682261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1096156Medicaid
LA1096156Medicaid