Provider Demographics
NPI:1417992249
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:EXECUTIVE DIRECTOR FOR MEDICAL SERV
Authorized Official - Prefix:
Authorized Official - First Name:LEISA
Authorized Official - Middle Name:P
Authorized Official - Last Name:OGLESBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-675-7629
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:LSUHSC-S CLINICS
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-7737
Mailing Address - Fax:318-675-5666
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:LSUHSC-S CLINICS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-7737
Practice Address - Fax:318-675-5666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA142204E00000X, 207K00000X, 207N00000X, 207P00000X, 207Q00000X, 207R00000X, 207U00000X, 207V00000X, 207W00000X, 207X00000X, 207Y00000X, 207ZP0102X, 208000000X, 2084P0800X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1157881Medicaid
LA1157881Medicaid