Basic Information
| Provider Information | |||||||||
| NPI: | 1922596170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
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| OtherOrganizationName: | SHRINERS HOSPITALS FOR CHILDREN PROFESSIONAL ANESTHESIA SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 LOCKBOX #7642 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132810300 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SAMFORD AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182225704 | ||||||||
| FaxNumber: | 3184247610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2018 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | GANTT | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8132810300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.