Basic Information
| Provider Information | |||||||||
| NPI: | 1679617849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHRINERS HOSPITALS FOR CHILDREN SHREVEPORT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
| Address2: | P.O. BOX 8500, LOCKBOX #7642 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818657 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SAMFORD AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182225704 | ||||||||
| FaxNumber: | 3184247610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 03/07/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | GARRY | ||||||||
| AuthorizedOfficialMiddleName: | KIM | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3182225704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 179 | LA | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 149229 | 05 | AL | MEDICAID | 258361 | 01 | LA | MEDICARE PART B (PTAN) | OTHER | 2700031 | 05 | LA | MEDICAID | 200341270A | 05 | OK | MEDICAID | 191748105 | 05 | AR | MEDICAID | 08155267 | 05 | MS | MEDICAID | 3168429 | 05 | TX | MEDICAID | 179 | 01 | LA | HOSPITAL LICENSE NUMBER | OTHER |