Basic Information
| Provider Information | |||||||||
| NPI: | 1568768679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF SOUTH PSYCHIATRY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1924 CORPORATE SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704583164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857810548 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1924 CORPORATE SQUARE DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704583164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857810548 | ||||||||
| FaxNumber: | 9857814319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2011 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | MALLIK | ||||||||
| AuthorizedOfficialFirstName: | HARMINDER | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9857810548 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | MD10912R | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | MD10912R | 01 | LA | STATE LICENSE10912R | OTHER |