Provider Demographics
NPI:1568768679
Name:GULF SOUTH PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:GULF SOUTH PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARMINDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:MALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-781-0548
Mailing Address - Street 1:1924 CORPORATE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3164
Mailing Address - Country:US
Mailing Address - Phone:985-781-0548
Mailing Address - Fax:
Practice Address - Street 1:1924 CORPORATE SQUARE DR
Practice Address - Street 2:SUITE D
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3164
Practice Address - Country:US
Practice Address - Phone:985-781-0548
Practice Address - Fax:985-781-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD10912R2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD10912ROtherSTATE LICENSE10912R