Provider Demographics
NPI:1861415895
Name:SOUTHERN BARIATRIC ASSOCIATES
Entity type:Organization
Organization Name:SOUTHERN BARIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-234-3000
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-0249
Mailing Address - Country:US
Mailing Address - Phone:985-234-3000
Mailing Address - Fax:985-234-3002
Practice Address - Street 1:7015 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4960
Practice Address - Country:US
Practice Address - Phone:985-234-3000
Practice Address - Fax:985-234-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA92030365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty