Provider Demographics
NPI:1861484842
Name:NORTHLAKE GASTROENTEROLOGY
Entity Type:Organization
Organization Name:NORTHLAKE GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-542-1334
Mailing Address - Street 1:16061 DOCTORS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1479
Mailing Address - Country:US
Mailing Address - Phone:985-542-1334
Mailing Address - Fax:985-318-1004
Practice Address - Street 1:16061 DOCTORS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1479
Practice Address - Country:US
Practice Address - Phone:985-542-1334
Practice Address - Fax:985-318-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherTAX ID NUMBER