=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679617849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHRINERS HOSPITALS FOR CHILDREN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2007
-----------------------------------------------------
Last Update Date | 03/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 SAMFORD AVE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71103-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-222-5704
-----------------------------------------------------
Fax | 318-424-7610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SHRINERS HOSPITALS FOR CHILDREN P.O. BOX 8500, LOCKBOX #7642
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19178-7642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-281-8657
-----------------------------------------------------
Fax | 813-281-8113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. GARRY KIM GREEN
-----------------------------------------------------
Credential | FACHE
-----------------------------------------------------
Telephone | 318-222-5704
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC2000X
-----------------------------------------------------
Taxonomy Name | Children's Hospital
-----------------------------------------------------
License Number | 179
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------