Provider Demographics
NPI:1881800886
Name:BRIAN LIND GAMBORG MD APMC
Entity type:Organization
Organization Name:BRIAN LIND GAMBORG MD APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBORG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-527-8087
Mailing Address - Street 1:1114 STELLY LN
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5139
Mailing Address - Country:US
Mailing Address - Phone:337-527-7087
Mailing Address - Fax:337-527-9831
Practice Address - Street 1:1114 STELLY LN
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5139
Practice Address - Country:US
Practice Address - Phone:337-527-7087
Practice Address - Fax:337-527-9831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449491Medicaid
LADF0205Medicare PIN
LA5C554Medicare PIN