Provider Demographics
NPI:1649438532
Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity type:Organization
Organization Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTAK
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:318-675-7737
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE - NEPHROLOGY SECTION
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-7402
Mailing Address - Fax:318-675-5913
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE - SECTION OF NEPHROLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-424-4008
Practice Address - Fax:318-424-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA142207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444715Medicaid
LA5CC98Medicare PIN