Healthcare Provider Details

I. General information

NPI: 1740398528
Provider Name (Legal Business Name): GARY R GLYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 FOUCHER STREET M1005
NEW ORLEANS LA
70115
US

IV. Provider business mailing address

1401 FOUCHER STREET M1005
NEW ORLEANS LA
70115
US

V. Phone/Fax

Practice location:
  • Phone: 504-897-8543
  • Fax: 504-897-8726
Mailing address:
  • Phone: 504-897-8543
  • Fax: 504-897-8726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number12725
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: