Provider Demographics
NPI:1245667823
Name:DR. GARY BIRDSALL MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:DR. GARY BIRDSALL MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRDSALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-632-5222
Mailing Address - Street 1:102 W 112TH ST
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-3628
Mailing Address - Country:US
Mailing Address - Phone:985-632-5222
Mailing Address - Fax:985-632-4222
Practice Address - Street 1:102 W 112TH ST
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-3628
Practice Address - Country:US
Practice Address - Phone:985-632-5222
Practice Address - Fax:985-632-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366145Medicaid
B64158Medicare UPIN