Provider Demographics
NPI:1396825816
Name:GREMILLION, MARCIA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:LYNN
Last Name:GREMILLION
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 SUMMA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3465
Mailing Address - Country:US
Mailing Address - Phone:225-757-0552
Mailing Address - Fax:225-763-9997
Practice Address - Street 1:100 WOMANS WAY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5100
Practice Address - Country:US
Practice Address - Phone:225-924-8264
Practice Address - Fax:225-924-8242
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0204722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1968056Medicaid
LA1968056Medicaid
LA5R697Medicare ID - Type Unspecified