Healthcare Provider Details

I. General information

NPI: 1568803732
Provider Name (Legal Business Name): SHRINERS HOSPITALS FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SAMFORD AVE
SHREVEPORT LA
71103-4239
US

IV. Provider business mailing address

PO BOX 8500 LOCKBOX #7642
PHILADELPHIA PA
19178-7642
US

V. Phone/Fax

Practice location:
  • Phone: 318-222-5704
  • Fax: 318-424-7610
Mailing address:
  • Phone: 318-222-5704
  • Fax: 318-424-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY G. GANTT
Title or Position: PRESIDENT
Credential:
Phone: 813-281-0300