Provider Demographics
NPI:1306862941
Name:MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC CENTER
Entity Type:Organization
Organization Name:MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC CENTER
Other - Org Name:MGA GASTROINTESTINAL DIAGNOSTIC AND THERAPEUTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:PO BOX 1187
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-1187
Mailing Address - Country:US
Mailing Address - Phone:504-349-6423
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:S450
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1980714Medicaid
11051Medicare PIN