Basic Information
| Provider Information | |||||||||
| NPI: | 1700856101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATES | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 | ||||||||
| Address2: | LOCKBOX 7642 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818478 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SAMFORD AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182263306 | ||||||||
| FaxNumber: | 3182263319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 11/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 10329R | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | E8504 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1698857 | 05 | LA | MEDICAID |