Healthcare Provider Details

I. General information

NPI: 1568768679
Provider Name (Legal Business Name): GULF SOUTH PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 CORPORATE SQUARE DR SUITE D
SLIDELL LA
70458-3164
US

IV. Provider business mailing address

1924 CORPORATE SQUARE DR
SLIDELL LA
70458-3164
US

V. Phone/Fax

Practice location:
  • Phone: 985-781-0548
  • Fax: 985-781-4319
Mailing address:
  • Phone: 985-781-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberMD10912R
License Number StateLA

VIII. Authorized Official

Name: HARMINDER S MALLIK
Title or Position: PRESIDENT
Credential: MD
Phone: 985-781-0548