Provider Demographics
NPI:1548594419
Name:COY W GAMMAGE JR APMC
Entity Type:Organization
Organization Name:COY W GAMMAGE JR APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GAMMAGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-325-7007
Mailing Address - Street 1:P O BOX 6137
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-6137
Mailing Address - Country:US
Mailing Address - Phone:318-325-7007
Mailing Address - Fax:318-699-0025
Practice Address - Street 1:1162 OLIVER ROAD
Practice Address - Street 2:SUITE 7
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-325-7007
Practice Address - Fax:318-699-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
830005032OtherRRMC
LA1976652Medicaid
LA1976652Medicaid