Basic Information
Provider Information | |||||||||
NPI: | 1427536325 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY HEALTH SHREVEPORT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OCHSNER LSU HEALTH SHREVEPORT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1541 KINGS HWY | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711034228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186260000 | ||||||||
FaxNumber: | 3186755666 | ||||||||
Practice Location | |||||||||
Address1: | 1541 KINGS HWY | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711034228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186260000 | ||||||||
FaxNumber: | 3186757531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2018 | ||||||||
LastUpdateDate: | 10/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GREEN | ||||||||
AuthorizedOfficialFirstName: | MITZI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3185198816 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 142 | LA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 01370170 | 05 | KY |   | MEDICAID | 1737712 | 05 | LA |   | MEDICAID | 0020300 | 05 | MS |   | MEDICAID | 00537776X | 05 | GA |   | MEDICAID | 108357105 | 05 | AR |   | MEDICAID | 720702002-001 | 05 | IL |   | MEDICAID | 124387 | 05 | MI |   | MEDICAID | 1705675 | 05 | LA |   | MEDICAID | 0508374 | 05 | IA |   | MEDICAID | 100038750 | 05 | IN |   | MEDICAID | 95012621 | 05 | CO |   | MEDICAID | 190098 | 01 |   | MEDICARE | OTHER | HS8470P | 05 | AK |   | MEDICAID | 026874 | 05 | AZ |   | MEDICAID | H0S0098N | 05 | AL |   | MEDICAID | 1444405 | 05 | LA |   | MEDICAID | 190098 | 01 | LA | MEDICARE | OTHER | 793527700 | 05 | MN |   | MEDICAID |