Provider Demographics
NPI:1528395621
Name:LOUISIANA STATE UNIVERSITY
Entity Type:Organization
Organization Name:LOUISIANA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OF SECTION OF P.M.&R.
Authorized Official - Prefix:PROF
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-568-4624
Mailing Address - Street 1:2020 GRAVIER ST FL 7
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2272
Mailing Address - Country:US
Mailing Address - Phone:504-568-5722
Mailing Address - Fax:504-568-2127
Practice Address - Street 1:5213 CITRUS BLVD APT S335
Practice Address - Street 2:
Practice Address - City:RIVER RIDGE
Practice Address - State:LA
Practice Address - Zip Code:70123-7229
Practice Address - Country:US
Practice Address - Phone:504-343-2858
Practice Address - Fax:504-568-2127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ42398-66787261QR0400X, 273Y00000X, 282E00000X, 283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No273Y00000XHospital UnitsRehabilitation Unit
No282E00000XHospitalsLong Term Care Hospital
No283X00000XHospitalsRehabilitation Hospital