Healthcare Provider Details

I. General information

NPI: 1962674713
Provider Name (Legal Business Name): LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST
MONROE LA
71202-6400
US

IV. Provider business mailing address

1501 KINGS HWY SHARED BILLING SERVICES
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7000
  • Fax: 318-675-5666
Mailing address:
  • Phone: 318-675-5000
  • Fax: 318-675-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number142
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number142
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number142
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number142
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number142
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number142
License Number StateLA
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number142
License Number StateLA

VIII. Authorized Official

Name: MRS. MELANIE H SOTAK
Title or Position: DIRECTOR OF MANAGED CARE
Credential: MHSA
Phone: 318-675-7737