Provider Demographics
NPI:1356484703
Name:HARGRODER MEDICAL, INC.
Entity Type:Organization
Organization Name:HARGRODER MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:HARGRODER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-684-5232
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:CHURCH POINT
Mailing Address - State:LA
Mailing Address - Zip Code:70525-0407
Mailing Address - Country:US
Mailing Address - Phone:337-684-5232
Mailing Address - Fax:337-684-3434
Practice Address - Street 1:3501 HIGHWAY 190 STE X
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-5129
Practice Address - Country:US
Practice Address - Phone:337-580-7544
Practice Address - Fax:337-580-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1038458Medicaid
LA1038458Medicaid