Basic Information
| Provider Information | |||||||||
| NPI: | 1336169275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGGERSTEDT | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF SURGERY, CARDIOVASCULAR | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188132655 | ||||||||
| FaxNumber: | 3188132673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF SURGERY, CARDIOVASCULAR | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188132655 | ||||||||
| FaxNumber: | 3188132673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 07090R | LA | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | 07090R | LA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1359998 | 05 | LA | MEDICAID |