Healthcare Provider Details

I. General information

NPI: 1861415895
Provider Name (Legal Business Name): SOUTHERN BARIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015 HIGHWAY 190 EAST SERVICE RD
COVINGTON LA
70433-4960
US

IV. Provider business mailing address

PO BOX 249
MADISONVILLE LA
70447-0249
US

V. Phone/Fax

Practice location:
  • Phone: 985-234-3000
  • Fax: 985-234-3002
Mailing address:
  • Phone: 985-234-3000
  • Fax: 985-234-3002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number92030365
License Number StateLA

VIII. Authorized Official

Name: GLENN GRAY
Title or Position: CEO
Credential:
Phone: 985-234-3000