Healthcare Provider Details

I. General information

NPI: 1639389026
Provider Name (Legal Business Name): ANESTHESIA SERVICES OF SHREVEPORT-BOSSIER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 E 70TH ST SUITE B
SHREVEPORT LA
71105-5347
US

IV. Provider business mailing address

PO BOX 52448
SHREVEPORT LA
71135-2448
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-1743
  • Fax: 318-797-7599
Mailing address:
  • Phone: 318-797-1743
  • Fax: 318-797-7599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number015590
License Number StateLA

VIII. Authorized Official

Name: DR. WINSTON E MOORE JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 318-797-1743