Provider Demographics
NPI:1861671869
Name:MID-CITY FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:MID-CITY FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-3525
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-0629
Mailing Address - Country:US
Mailing Address - Phone:318-221-3525
Mailing Address - Fax:
Practice Address - Street 1:838 MARGARET PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4509
Practice Address - Country:US
Practice Address - Phone:318-221-3525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CD17Medicare UPIN