=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710281431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAHID MANSOOR, M.D. A PROFESSIONAL MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2011
-----------------------------------------------------
Last Update Date | 03/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 MEDICAL CENTER DR STE 3A
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-8124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-484-3899
-----------------------------------------------------
Fax | 318-484-3887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 338 MOREAU ST STE E
-----------------------------------------------------
City | MARKSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71351-2957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-253-7022
-----------------------------------------------------
Fax | 318-253-7944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. KRISTA RACHAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-484-3899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 13654R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------