Provider Demographics
NPI:1457531089
Name:NORTHWEST SURGICAL SPECIALISTS INC.
Entity Type:Organization
Organization Name:NORTHWEST SURGICAL SPECIALISTS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-675-1322
Mailing Address - Street 1:1801 FAIRFIELD AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4468
Mailing Address - Country:US
Mailing Address - Phone:318-675-1322
Mailing Address - Fax:318-675-1332
Practice Address - Street 1:1801 FAIRFIELD AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4468
Practice Address - Country:US
Practice Address - Phone:318-675-1322
Practice Address - Fax:318-675-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2014002086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1041611Medicaid
LA5DB46Medicare PIN