Provider Demographics
NPI:1972591170
Name:DERMATOLOGY CLINIC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DERMATOLOGY CLINIC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURGLASS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:225-769-7546
Mailing Address - Street 1:5326 O'DONOVAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9153
Mailing Address - Country:US
Mailing Address - Phone:225-769-7546
Mailing Address - Fax:225-769-0471
Practice Address - Street 1:5326 O'DONOVAN DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9153
Practice Address - Country:US
Practice Address - Phone:225-769-7546
Practice Address - Fax:225-769-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1113247Medicaid
LA1113247Medicaid