MEDICARE: SHREVEPORT FAMILY MEDICINE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1003975079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHREVEPORT FAMILY MEDICINE INC

Provider Business Mailing Address
First Line	:	7505 PINES RD
Second Line	:	SUITE 1250
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-3935
Country	:	US
Telephone Number	:	318-686-3770
Fax Number	:	318-686-3838

Provider Business Practice Location Address
First Line	:	7505 PINES ROAD
Second Line	:	SUITE 1250
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-3927
Country	:	US
Telephone Number	:	318-686-3770
Fax Number	:	318-686-3838

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. SHELIA L. JACKSON
Credential	:
Telephone Number	:	318-686-3770

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	06/16/2008

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Directions to “SHREVEPORT FAMILY MEDICINE INC ” Practice Location

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