Southern Pediatric Clinic

Primary specialty

Health Service Clinic/CenterTaxonomy code 261QH0100X

License

MD12866R Issued in LA

Legal business name

SOUTHERN PEDIATRIC CLINIC

Practice address

202 N Thomas Dr
Suite 1
Shreveport, LA 71107-6539

Phone

(318) 221-0277

Fax

(318) 221-3277

NPI assigned

Oct 8, 2015

Organization subpart

No

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) 221-0277

Specialties & licenses 1

Addresses

Other identifiers 1

Tax ID family

Southern Pediatric Clinic5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

• Southern Pediatric Clinic

  • Health Service Clinic/Center
  • Oakdale, LA
  • NPI 1104296417
  NPD tax ID
• Southern Pediatric Clinic

  • Pediatrics Physician
  • Alexandria, LA
  • NPI 1487766804
  NPD tax ID
• Southern Pediatric Clinic

  • Primary Care Clinic/Center
  • Shreveport, LA
  • NPI 1508237256
  NPD tax ID
• Southern Pediatric Clinic

  • Primary Care Clinic/Center
  • Shreveport, LA
  • NPI 1528432440
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1444262400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1446508800000",
    "number": "1104297720",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "202 N THOMAS DR",
            "address_2": "SUITE 1",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711076539",
            "telephone_number": "318-221-0277",
            "fax_number": "318-221-3277"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "202 N THOMAS DR",
            "address_2": "SUITE 1",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711076539",
            "telephone_number": "318-221-0277",
            "fax_number": "318-221-3277"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN PEDIATRIC CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-08",
        "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": "318-221-0277",
        "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": []
}

• South Shreveport Internal Medicine
• Southern Hills LLC
• Southern Kidney Associates PLLC
• Southern Oaks Nursing & Rehabilitation Center, LLC
• Southern Oaks Properties, LLC
• Southern Pediatric Clinic
• Southern Pediatric Clinic
• Southern Root Dentistry LLC
• James Wesley Southern
• Southfield Family Dentistry, Inc.

• Health Service Clinic/Center in Shreveport, LA
• Providers in Shreveport, LA by specialty
• Health Service Clinic/Center in Louisiana

• 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.

Verify at the official NPI Registry.