Healthcare Provider Details

I. General information

NPI: 1508522558
Provider Name (Legal Business Name): OCHSNER LSU HEALTH SHREVEPORT - ST. MARY MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT MARY PL
SHREVEPORT LA
71101-4307
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-4300
  • Fax:
Mailing address:
  • Phone: 318-626-0284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: VERNON MOORE
Title or Position: CFO
Credential:
Phone: 318-626-0990