Provider Demographics
NPI:1700838513
Name:SHREVEPORT INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:SHREVEPORT INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAYNIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-621-2929
Mailing Address - Street 1:1449 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-629-0220
Mailing Address - Fax:
Practice Address - Street 1:1449 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-629-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty