Provider Demographics
NPI:1629279468
Name:SHREVEPORT DOCTORS' HOSPITAL
Entity Type:Organization
Organization Name:SHREVEPORT DOCTORS' HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-678-4206
Mailing Address - Street 1:PO BOX 676689
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6689
Mailing Address - Country:US
Mailing Address - Phone:972-705-5134
Mailing Address - Fax:
Practice Address - Street 1:1130 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3908
Practice Address - Country:US
Practice Address - Phone:318-227-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1749150Medicaid
LA19-S115Medicare ID - Type Unspecified