Basic Information
| Provider Information | |||||||||
| NPI: | 1861554297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHREVEPORT ANESTHESIA SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9441 LBJ FWY STE 400 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752434500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726646963 | ||||||||
| FaxNumber: | 7702374731 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726646900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3186354269 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1949124 | 05 | LA | MEDICAID | CE9481 | 01 | LA | RAILROAD MEDICARE | OTHER |