Basic Information
| Provider Information | |||||||||
| NPI: | 1912909912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRFHH SHREVEPORT LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY HEALTH SHREVEPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1541 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186260000 | ||||||||
| FaxNumber: | 3186757531 | ||||||||
| Practice Location | |||||||||
| Address1: | 1541 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186260000 | ||||||||
| FaxNumber: | 3186757531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | VERNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3186260000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 282N00000X | 142 | LA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 124387 | 05 | MI | MEDICAID | 1444405 | 05 | LA | MEDICAID | 1705675 | 05 | LA | MEDICAID | 793527700 | 05 | MN | MEDICAID | 720702002-001 | 05 | IL | MEDICAID | H0S0098N | 05 | AL | MEDICAID | 00537776X | 05 | GA | MEDICAID | 108357105 | 05 | AR | MEDICAID | HS8470P | 05 | AK | MEDICAID | 0020300 | 05 | MS | MEDICAID | 1737712 | 05 | LA | MEDICAID | 026874 | 05 | AZ | MEDICAID | 0508374 | 05 | IA | MEDICAID | 01370170 | 05 | KY | MEDICAID | 100038750 | 05 | IN | MEDICAID | 95012621 | 05 | CO | MEDICAID |