Provider Demographics
NPI:1982676771
Name:SHREVEPORT ENDOSCOPY CENTER, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SHREVEPORT ENDOSCOPY CENTER, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SATHYA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGANMOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-631-0072
Mailing Address - Street 1:3217 MABEL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4022
Mailing Address - Country:US
Mailing Address - Phone:318-631-0072
Mailing Address - Fax:318-213-4979
Practice Address - Street 1:3217 MABEL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4022
Practice Address - Country:US
Practice Address - Phone:318-631-0072
Practice Address - Fax:318-213-4979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA50OtherSTATE LICENSE
LA1910678Medicaid
LAFS0747230OtherDEA
LA11042Medicare PIN