Provider Demographics
NPI:1871523423
Name:GARDEN PARK PHYSICIAN SERVICES CORP
Entity type:Organization
Organization Name:GARDEN PARK PHYSICIAN SERVICES CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-988-7044
Mailing Address - Street 1:12330 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2737
Mailing Address - Country:US
Mailing Address - Phone:228-863-7117
Mailing Address - Fax:228-868-9388
Practice Address - Street 1:12330 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2737
Practice Address - Country:US
Practice Address - Phone:228-863-7117
Practice Address - Fax:228-868-9388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016019Medicaid
MSC02318Medicare PIN