Healthcare Provider Details

I. General information

NPI: 1407885791
Provider Name (Legal Business Name): INPATIENT PEDIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 MEDICAL PARK DR
MONROE LA
71203-2355
US

IV. Provider business mailing address

1601 LAMY LN
MONROE LA
71201-3735
US

V. Phone/Fax

Practice location:
  • Phone: 318-387-3453
  • Fax: 318-323-9045
Mailing address:
  • Phone: 318-387-3453
  • Fax: 318-323-9045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MITRA GREEN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 318-387-3453