Provider Demographics
NPI:1255899936
Name:DELUXE MEDICAL CORPORATION
Entity type:Organization
Organization Name:DELUXE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BERTRAND
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:504-418-5226
Mailing Address - Street 1:3640 LAKE ASPEN DR W
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-8303
Mailing Address - Country:US
Mailing Address - Phone:504-418-4226
Mailing Address - Fax:504-365-9902
Practice Address - Street 1:3640 LAKE ASPEN DR W
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-8303
Practice Address - Country:US
Practice Address - Phone:504-418-4226
Practice Address - Fax:504-365-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty