=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760461875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MORGAN CARLISLE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2006
-----------------------------------------------------
Last Update Date | 10/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ONE SAINT MARY PLACE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71101-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-681-6812
-----------------------------------------------------
Fax | 318-681-7185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ONE SAINT MARY PLACE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71101-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-681-6812
-----------------------------------------------------
Fax | 318-684-7185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 14004R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD.14004R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD60821843
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------