Provider Demographics
NPI:1225029515
Name:FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4571
Mailing Address - Street 1:7813 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5505
Mailing Address - Country:US
Mailing Address - Phone:318-212-3830
Mailing Address - Fax:318-212-3835
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 900
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-3830
Practice Address - Fax:318-212-3835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1797031Medicaid
LA57122Medicare PIN