Provider Demographics
NPI:1003975079
Name:SHREVEPORT FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:SHREVEPORT FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-686-3770
Mailing Address - Street 1:7505 PINES RD
Mailing Address - Street 2:SUITE 1250
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3935
Mailing Address - Country:US
Mailing Address - Phone:318-686-3770
Mailing Address - Fax:318-686-3838
Practice Address - Street 1:7505 PINES ROAD
Practice Address - Street 2:SUITE 1250
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3927
Practice Address - Country:US
Practice Address - Phone:318-686-3770
Practice Address - Fax:318-686-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty