1992925135 NPI number — SHREVEPORT SURGERY CENTER PTRSHP

Table of content: (NPI 1992925135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992925135 NPI number — SHREVEPORT SURGERY CENTER PTRSHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHREVEPORT SURGERY CENTER PTRSHP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHREVEPORT SURGERY ANESTHESIA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992925135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4825
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71134-0825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-227-1163
Provider Business Mailing Address Fax Number:
318-227-0413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
745 OLIVE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71104-2246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-227-1163
Provider Business Practice Location Address Fax Number:
318-227-0413
Provider Enumeration Date:
04/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRIDGES
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
318-227-1163

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1900G9962Z . This is a "MEDICAL STAFF # BCBS LA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1447552 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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