Provider Demographics
NPI:1649993585
Name:SOUTH BOSSIER MEDICAL
Entity type:Organization
Organization Name:SOUTH BOSSIER MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-375-4001
Mailing Address - Street 1:5260 BARKSDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5668 BARKSDALE BLVD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112
Practice Address - Country:US
Practice Address - Phone:318-735-1800
Practice Address - Fax:318-725-4960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH CADDO HOSPITAL SERVICE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-26
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care