Provider Demographics
NPI:1598804486
Name:SHREVEPORT SURGERY CENTER PTRSHP
Entity Type:Organization
Organization Name:SHREVEPORT SURGERY CENTER PTRSHP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-227-1163
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134-0825
Mailing Address - Country:US
Mailing Address - Phone:318-227-1163
Mailing Address - Fax:
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-227-1163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1334073Medicaid
LA21026OtherBLUE CROSS BLUE SHIELD
LA1334073Medicaid