SOUTHERN PEDIATRIC CLINIC NPI 1104297720

NPI Information

NPI: 1104297720
Provider Name: SOUTHERN PEDIATRIC CLINIC
Classification: Clinic/Center - 261QH0100X
Entity Type: Organization

Specialization: Health Service

Address:
202 N THOMAS DR
SUITE 1
SHREVEPORT, LA
ZIP 71107
Phone: (318) 221-0277
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SOUTHERN PEDIATRIC CLINIC is a health service clinic center in Shreveport, LA. SOUTHERN PEDIATRIC CLINIC NPI is 1104297720. The provider is registered as an organization entity type.

The provider's business location address is:

202 N THOMAS DR
SUITE 1
SHREVEPORT, LA
ZIP 71107-539
Phone: (318) 221-0277
Fax: (318) 221-3277

The provider's authorized official is Stella Grace Immanuel .
The authorized official title is Owner and has the following contact phone number (318) 221-0277.

The enumeration date for this NPI number is 10/8/2015 and was last updated on 11/3/2015.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QH0100X	Clinic/Center	Health Service	MD12866R	LOUISIANA	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	1449237	MEDICAID	LOUISIANA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

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