Provider Demographics
NPI:1487766804
Name:SOUTHERN PEDIATRIC CLINIC
Entity type:Organization
Organization Name:SOUTHERN PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:IMMANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-730-9760
Mailing Address - Street 1:5910 DUBLIN RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-5234
Mailing Address - Country:US
Mailing Address - Phone:318-561-4200
Mailing Address - Fax:318-561-4205
Practice Address - Street 1:1416 METRO DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3424
Practice Address - Country:US
Practice Address - Phone:318-561-4200
Practice Address - Fax:318-561-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449237Medicaid