Provider Demographics
NPI:1952975104
Name:GANNON MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:GANNON MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-718-3764
Mailing Address - Street 1:124 KAROLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3505
Mailing Address - Country:US
Mailing Address - Phone:225-718-3764
Mailing Address - Fax:
Practice Address - Street 1:607 RUE DE BRILLE
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2169
Practice Address - Country:US
Practice Address - Phone:337-367-1247
Practice Address - Fax:337-365-7496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty