1992888101 NPI number — LSUMC-S FAMILY PRACTICE MEDICAL

Table of content: (NPI 1992888101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992888101 NPI number — LSUMC-S FAMILY PRACTICE MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LSUMC-S FAMILY PRACTICE MEDICAL
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:
LSUHSC-S FAMILY MEDICINE RESIDENCY PROGRAM
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:
1992888101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75373-5328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-441-1030
Provider Business Mailing Address Fax Number:
318-441-1050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 4TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71301-8411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-441-1030
Provider Business Practice Location Address Fax Number:
318-441-1050
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OGLESBY
Authorized Official First Name:
LEISA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
EXECUTIVE DIR FOR MEDICAL SERVICES
Authorized Official Telephone Number:
318-675-7629

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1948705 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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