=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710041900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHREVEPORT INTERNAL MEDICINE AND PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 09/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10401 E KINGS HWY
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71115-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-558-0880
-----------------------------------------------------
Fax | 318-562-6354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10401 E KINGS HWY
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71115-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-588-0880
-----------------------------------------------------
Fax | 318-562-6354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALLAN S MATRIANO LIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 318-588-0880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------