1316119167 NPI number — LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER

Table of content: (NPI 1316119167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316119167 NPI number — LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
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:
COMPHREHENSIVE CLINIC OF MONROE
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:
1316119167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 KINGS HWY
Provider Second Line Business Mailing Address:
SHARED BILLING SERVICES
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71103-4228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-675-5000
Provider Business Mailing Address Fax Number:
318-675-5666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4864 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71202-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-330-7000
Provider Business Practice Location Address Fax Number:
318-675-5666
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SOTAK
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
H
Authorized Official Title or Position:
DIRECTOR OF MANAGED CARE
Authorized Official Telephone Number:
318-675-7737

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  142 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 142 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 142 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 142 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1947288 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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