Healthcare Provider Details

I. General information

NPI: 1619463916
Provider Name (Legal Business Name): GULFSOUTH PULMONOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 N HIGHWAY 190
COVINGTON LA
70433
US

IV. Provider business mailing address

PO BOX 3370
COVINGTON LA
70434-3370
US

V. Phone/Fax

Practice location:
  • Phone: 985-400-5988
  • Fax: 985-867-3644
Mailing address:
  • Phone: 985-400-5988
  • Fax: 985-867-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDI OGDEN
Title or Position: BILLING MANAGER
Credential:
Phone: 985-400-5988