MEDICARE: HIGHLAND CLINIC, A PROF MED CORP

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	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1740897743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHLAND CLINIC, A PROF MED CORP

Provider Business Mailing Address
First Line	:	1455 E BERT KOUNS INDUSTRIAL LOOP
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5634
Country	:	US
Telephone Number	:	318-798-4500
Fax Number	:	318-798-4601

Provider Business Practice Location Address
First Line	:	5025 SHED RD
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5434
Country	:	US
Telephone Number	:	318-795-4741
Fax Number	:	318-795-4742

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MICHAEL GUSTAVSON
Credential	:
Telephone Number	:	318-798-4465

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	06/02/2026

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