Provider Demographics
NPI:1568803732
Name:SHRINERS HOSPITALS FOR CHILDREN
Entity Type:Organization
Organization Name:SHRINERS HOSPITALS FOR CHILDREN
Other - Org Name:SHRINERS HOSPITALS FOR CHILDREN (PROFESSIONAL SERVICES)
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GANTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-281-0300
Mailing Address - Street 1:PO BOX 8500
Mailing Address - Street 2:LOCKBOX #7642
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:318-222-5704
Mailing Address - Fax:318-424-7610
Practice Address - Street 1:3100 SAMFORD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4239
Practice Address - Country:US
Practice Address - Phone:318-222-5704
Practice Address - Fax:318-424-7610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL149229Medicaid
OK200341270Medicaid
AR191748105Medicaid
LA2700031Medicaid
193301Medicare PIN