Provider Demographics
NPI:1801895495
Name:BYRD MEDICAL CLINIC INC
Entity type:Organization
Organization Name:BYRD MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSO DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:CROCKETT
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-392-6200
Mailing Address - Street 1:700 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 S 6TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4719
Practice Address - Country:US
Practice Address - Phone:337-392-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207X00000X, 207Y00000X, 208600000X, 208800000X
LA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1944718Medicaid
LA1944718Medicaid
LA5D639Medicare PIN