Provider Demographics
NPI:1972623049
Name:MG DESALVO MD&GM GREMILLION MDAMC
Entity Type:Organization
Organization Name:MG DESALVO MD&GM GREMILLION MDAMC
Other - Org Name:MICHAEL G. DESALVO, MD, A MED. CORP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-885-4677
Mailing Address - Street 1:3645 HOUMA BLVD
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4229
Mailing Address - Country:US
Mailing Address - Phone:504-885-4677
Mailing Address - Fax:504-888-0549
Practice Address - Street 1:3645 HOUMA BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4229
Practice Address - Country:US
Practice Address - Phone:504-885-4677
Practice Address - Fax:504-888-0549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Y00000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1149179Medicaid
LA5C242Medicare PIN