Healthcare Provider Details

I. General information

NPI: 1134993579
Provider Name (Legal Business Name): GERIPALMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 02/17/2024
Certification Date: 02/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 S SHERWOOD FOREST BLVD STE 650
BATON ROUGE LA
70816-5216
US

IV. Provider business mailing address

3636 S SHERWOOD FOREST BLVD STE 650
BATON ROUGE LA
70816-5216
US

V. Phone/Fax

Practice location:
  • Phone: 240-437-4362
  • Fax:
Mailing address:
  • Phone: 240-437-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TOLULOPE FAMUYIRO
Title or Position: PRIMARY CARE-GERIATRICS
Credential: MD
Phone: 240-437-4362