Provider Demographics
NPI:1437383106
Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:LSU SHREVEPORT HCL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SOTAK
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:318-675-7737
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DPEARTMENT OF SURGERY HISTOCOMPATIBILITY LABORATORY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6104
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DPEARTMENT OF SURGERY HISTOCOMPATIBILITY LABORATORY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D0951857291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19-HL01Medicare PIN