Basic Information
| Provider Information | |||||||||
| NPI: | 1962674713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER | ||||||||
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| OtherOrganizationName: | LSU CLINICS OF MONROE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | SHARED BILLING SERVICES | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
| FaxNumber: | 3186755666 | ||||||||
| Practice Location | |||||||||
| Address1: | 4864 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712026400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183307000 | ||||||||
| FaxNumber: | 3186755666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOTAK | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 3186757737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MHSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 142 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 142 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | 142 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207W00000X | 142 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207ZP0102X | 142 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208000000X | 142 | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 142 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1792896 | 05 | LA | MEDICAID |