Provider Demographics
NPI:1508237256
Name:SOUTHERN PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:SOUTHERN PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:IMMANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-730-9760
Mailing Address - Street 1:4571 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2917
Mailing Address - Country:US
Mailing Address - Phone:318-934-0097
Mailing Address - Fax:
Practice Address - Street 1:4571 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2917
Practice Address - Country:US
Practice Address - Phone:318-934-0097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD12866R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care