Provider Demographics
NPI:1891168761
Name:HIGHLAND CLINIC, A PROF MED CORP
Entity Type:Organization
Organization Name:HIGHLAND CLINIC, A PROF MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-798-4598
Mailing Address - Street 1:1455 E BERT KOUN LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4500
Mailing Address - Fax:318-798-4555
Practice Address - Street 1:1400 E BERT KOUN LOOP
Practice Address - Street 2:#103
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5603
Practice Address - Country:US
Practice Address - Phone:318-222-8402
Practice Address - Fax:318-222-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1038300Medicaid
LA0438840003Medicare NSC
LA56742Medicare PIN