Provider Demographics
NPI:1952944894
Name:RED RIVER MEDICINE, LLC
Entity type:Organization
Organization Name:RED RIVER MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:TYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-549-0929
Mailing Address - Street 1:PO BOX 52364
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-2364
Mailing Address - Country:US
Mailing Address - Phone:318-798-4606
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-213-3800
Practice Address - Fax:318-213-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1423611Medicaid