Provider Demographics
NPI:1679617849
Name:SHRINERS HOSPITALS FOR CHILDREN
Entity Type:Organization
Organization Name:SHRINERS HOSPITALS FOR CHILDREN
Other - Org Name:SHRINERS HOSPITALS FOR CHILDREN SHREVEPORT
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:318-222-5704
Mailing Address - Street 1:SHRINERS HOSPITALS FOR CHILDREN
Mailing Address - Street 2:P.O. BOX 8500, LOCKBOX #7642
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8657
Mailing Address - Fax:813-281-8113
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:2007-02-19
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA179282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL149229Medicaid
LA258361OtherMEDICARE PART B (PTAN)
LA2700031Medicaid
OK200341270AMedicaid
AR191748105Medicaid
MS08155267Medicaid
TX3168429Medicaid
LA179OtherHOSPITAL LICENSE NUMBER
LA179OtherHOSPITAL LICENSE NUMBER