Provider Demographics
NPI:1790720738
Name:LOUISINA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:LOUISINA STATE UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:LSUHSC-S DEPARTMENT OF NEUROSURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-675-6426
Mailing Address - Street 1:1501 KINGS HIGHWAY
Mailing Address - Street 2:LSUHSC-S
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6426
Mailing Address - Fax:318-675-6862
Practice Address - Street 1:1501 KINGS HIGHWAY
Practice Address - Street 2:LSUHSC-S
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6426
Practice Address - Fax:318-675-6862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUISINA STATE UNIVERSITY HEALTH SCIENCES CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA142207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1944947Medicaid
LA5D924Medicare ID - Type Unspecified
LA5D924Medicare PIN