Provider Demographics
NPI:1710041900
Name:SHREVEPORT INTERNAL MEDICINE AND PEDIATRICS LLC
Entity type:Organization
Organization Name:SHREVEPORT INTERNAL MEDICINE AND PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATRIANO LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-588-0880
Mailing Address - Street 1:10401 E KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3227
Mailing Address - Country:US
Mailing Address - Phone:318-588-0880
Mailing Address - Fax:318-562-6354
Practice Address - Street 1:10401 E KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3227
Practice Address - Country:US
Practice Address - Phone:318-558-0880
Practice Address - Fax:318-562-6354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5W902Medicare ID - Type Unspecified
LA4A607Medicare ID - Type Unspecified
LA5H577Medicare ID - Type Unspecified