Provider Demographics
NPI:1881640795
Name:CANAL STREET CARDIOLOGY
Entity Type:Organization
Organization Name:CANAL STREET CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-273-6137
Mailing Address - Street 1:2820 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6302
Mailing Address - Country:US
Mailing Address - Phone:504-273-6137
Mailing Address - Fax:
Practice Address - Street 1:2820 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6302
Practice Address - Country:US
Practice Address - Phone:504-273-6137
Practice Address - Fax:504-304-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1320293Medicaid
LAB63852Medicare UPIN
LA1320293Medicaid