Basic Information
| Provider Information | |||||||||
| NPI: | 1740398528 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLYNN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 FOUCHER STREET | ||||||||
| Address2: | M1005 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978543 | ||||||||
| FaxNumber: | 5048978726 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 FOUCHER STREET | ||||||||
| Address2: | M1005 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978543 | ||||||||
| FaxNumber: | 5048978726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/29/2013 | ||||||||
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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 | 208100000X | 12725 | LA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1301680 | 05 | LA | MEDICAID |