Provider Demographics
NPI:1548494578
Name:PEDIATRIC PROVIDERS OF LOUISIANA
Entity type:Organization
Organization Name:PEDIATRIC PROVIDERS OF LOUISIANA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-621-9600
Mailing Address - Street 1:4140 HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-7818
Mailing Address - Country:US
Mailing Address - Phone:318-621-9600
Mailing Address - Fax:318-621-0169
Practice Address - Street 1:4140 HOLLYWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-7818
Practice Address - Country:US
Practice Address - Phone:318-621-9600
Practice Address - Fax:318-621-0169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06203R261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5D168Medicare PIN