Healthcare Provider Details

I. General information

NPI: 1568694610
Provider Name (Legal Business Name): MICHAEL GERHOLD RT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MAGNOLIA GARDENS DR
COVINGTON LA
70435-9520
US

IV. Provider business mailing address

50 MAGNOLIA GARDENS DR
COVINGTON LA
70435-9520
US

V. Phone/Fax

Practice location:
  • Phone: 972-834-6759
  • Fax:
Mailing address:
  • Phone: 972-834-6759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number1168
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberMRT4610
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: