Provider Demographics
NPI:1063717841
Name:PRACTICEMD, INC.
Entity type:Organization
Organization Name:PRACTICEMD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-841-4312
Mailing Address - Street 1:PO BOX 6657
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71136-6657
Mailing Address - Country:US
Mailing Address - Phone:318-841-4312
Mailing Address - Fax:318-841-4342
Practice Address - Street 1:242 LYNBROOK BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6548
Practice Address - Country:US
Practice Address - Phone:318-841-4312
Practice Address - Fax:318-841-4342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site