Active NPI
Southern Pediatric Clinic
- Health Service Clinic/Center
- Oakdale, LA
National Provider Identifier
1104296417
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Health Service Clinic/Center
- License
- MD12866R
- Legal business name
- SOUTHERN PEDIATRIC CLINIC
- Practice address
- 905 E 7TH Ave
Suite 9
Oakdale, LA 71463-2797 - Phone
- (318) 215-8150
- Fax
- (318) 215-8151
- NPI assigned
- Sep 29, 2015
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Stella Grace Immanuel, MD
- Title
- Owner
- Phone
- (318) 215-8150
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Health Service Clinic/Center | 261QH0100X | MD12866R | LA | Primary |
Addresses
Primary practice location
905 E 7TH Ave
Suite 9
Oakdale, LA 71463-2797
Mailing address
905 E 7TH Ave
Suite 9
Oakdale, LA 71463-2797
Phone (318) 215-8150
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1449237 | Medicaid | LA |
National Provider Directory
National Provider Directory- Tax ID family
- Southern Pediatric Clinic
Other organizations with this tax ID 4
Organizations that report the same tax identification number in the National Provider Directory.
-
- Health Service Clinic/Center
- Shreveport, LA
- NPI 1104297720
-
- Pediatrics Physician
- Alexandria, LA
- NPI 1487766804
-
- Primary Care Clinic/Center
- Shreveport, LA
- NPI 1508237256
-
- Primary Care Clinic/Center
- Shreveport, LA
- NPI 1528432440
Locations
905 E 7th Ave
Ste 9
Oakdale, LA 71463
Phone (318) 215-8150
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1443484800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1446508800000",
"number": "1104296417",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "905 E 7TH AVE",
"address_2": "SUITE 9",
"city": "OAKDALE",
"state": "LA",
"postal_code": "714632797",
"telephone_number": "318-215-8150",
"fax_number": "318-215-8151"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "905 E 7TH AVE",
"address_2": "SUITE 9",
"city": "OAKDALE",
"state": "LA",
"postal_code": "714632797",
"telephone_number": "318-215-8150",
"fax_number": "318-215-8151"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "SOUTHERN PEDIATRIC CLINIC",
"organizational_subpart": "NO",
"enumeration_date": "2015-09-29",
"last_updated": "2015-11-03",
"status": "A",
"authorized_official_last_name": "IMMANUEL",
"authorized_official_first_name": "STELLA",
"authorized_official_middle_name": "GRACE",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "318-215-8150",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "261QH0100X",
"taxonomy_group": "",
"desc": "Clinic/Center, Health Service",
"state": "LA",
"license": "MD12866R",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1449237",
"state": "LA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Oakdale, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 3, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.