=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821393505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLOBAL PHYSICIANS NETWORK TEXAS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 TEXAS ST SUITE 200
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71101-3524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-226-8202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 TEXAS ST SUITE 200
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71101-3524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-226-8202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. SCOTT MARKSTROM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-226-8202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------