Healthcare Provider Details

I. General information

NPI: 1992888101
Provider Name (Legal Business Name): LSUMC-S FAMILY PRACTICE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 4TH ST STE A
ALEXANDRIA LA
71301-8411
US

IV. Provider business mailing address

PO BOX 735328
DALLAS TX
75373-5328
US

V. Phone/Fax

Practice location:
  • Phone: 318-441-1030
  • Fax: 318-441-1050
Mailing address:
  • Phone: 318-441-1030
  • Fax: 318-441-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEISA P OGLESBY
Title or Position: EXECUTIVE DIR FOR MEDICAL SERVICES
Credential:
Phone: 318-675-7629