Provider Demographics
NPI:1629019047
Name:WEBB INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:WEBB INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-220-7047
Mailing Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 480
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5740
Mailing Address - Country:US
Mailing Address - Phone:318-220-7047
Mailing Address - Fax:
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 480
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5740
Practice Address - Country:US
Practice Address - Phone:318-220-7047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA721669340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1540030Medicaid
LA1540030Medicaid
LA5CG69Medicare PIN