MEDICARE: VICTORY MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1609204759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	8636 MARKS ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70118-4628
Country	:	US
Telephone Number	:	504-957-2336
Fax Number	:	504-942-8701

Provider Business Practice Location Address
First Line	:	9970 LAKE FOREST BLVD
Second Line	:	SUITE C
City	:	NEW ORLEANS
State	:	LA
Zip	:	70127-2609
Country	:	US
Telephone Number	:	504-957-2336
Fax Number	:	504-942-8700

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HERBERT PETER BURRELL
Credential	:
Telephone Number	:	504-957-2336

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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Directions to “VICTORY MEDICAL CLINIC ” Practice Location

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