Provider Demographics
NPI:1992839054
Name:GLENWOOD FAMILY PRACTICE AND OCCUPATIONAL HEALTH CENTER, INC
Entity Type:Organization
Organization Name:GLENWOOD FAMILY PRACTICE AND OCCUPATIONAL HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-387-5244
Mailing Address - Street 1:101 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8309
Mailing Address - Country:US
Mailing Address - Phone:318-387-5244
Mailing Address - Fax:318-387-5246
Practice Address - Street 1:101 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8309
Practice Address - Country:US
Practice Address - Phone:318-387-5244
Practice Address - Fax:318-387-5246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1107646Medicaid
LA1107646Medicaid
LAC67239Medicare UPIN