Provider Demographics
NPI:1891863403
Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:LSUHSC-S HISTO IMMUNOLOGY DIGANOSTIC LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SOTAK
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:318-675-7737
Mailing Address - Street 1:1541 KINGS HWY
Mailing Address - Street 2:LSU HISTO IMMUNOLOGY DIAGNOSTIC LAB
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-5000
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:LSU HISTO IMMUNOLOGY DIAGNOSTIC LAB
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1323861Medicaid
LA1323861Medicaid