Provider Demographics
NPI:1992925135
Name:SHREVEPORT SURGERY CENTER PTRSHP
Entity type:Organization
Organization Name:SHREVEPORT SURGERY CENTER PTRSHP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-227-1163
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134-0825
Mailing Address - Country:US
Mailing Address - Phone:318-227-1163
Mailing Address - Fax:318-227-0413
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-227-1163
Practice Address - Fax:318-227-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1900G9962ZOtherMEDICAL STAFF # BCBS LA
LA1447552Medicaid
LA1447552Medicaid