Provider Demographics
NPI:1982635249
Name:SOUTH SHREVEPORT INTERNAL MEDICINE
Entity Type:Organization
Organization Name:SOUTH SHREVEPORT INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4232
Mailing Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-212-5991
Mailing Address - Fax:318-212-5018
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 301
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-212-5991
Practice Address - Fax:318-212-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448885Medicaid
LA1448885Medicaid