Provider Demographics
NPI:1730406992
Name:DR PATRICK S GILLESPIE A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:DR PATRICK S GILLESPIE A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-826-8044
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70589-0698
Mailing Address - Country:US
Mailing Address - Phone:337-826-8044
Mailing Address - Fax:337-826-8048
Practice Address - Street 1:414 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:LA
Practice Address - Zip Code:70589-4282
Practice Address - Country:US
Practice Address - Phone:337-826-8044
Practice Address - Fax:337-826-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1913677Medicaid
LAE69762Medicare UPIN