Basic Information
| Provider Information | |||||||||
| NPI: | 1609868892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAUL | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32600 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711302600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124877 | ||||||||
| FaxNumber: | 3182124192 | ||||||||
| Practice Location | |||||||||
| Address1: | 8001 YOUREE DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711152302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123500 | ||||||||
| FaxNumber: | 3182123505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 022332 | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1677060 | 05 | LA | MEDICAID |