=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093028060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF SOUTH PRIMARY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2010
-----------------------------------------------------
Last Update Date | 07/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5145 BLUEBONNET BLVD
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70809-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-368-2480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5145 BLUEBONNET BLVD
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70809-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-368-2480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHEN GUILBAULT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-892-2872
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 025275
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------