Southern Pediatric Clinic

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

Legal business name

SOUTHERN PEDIATRIC CLINIC

Practice address

1416 Metro Dr
Alexandria, LA 71301-3424

Phone

(318) 561-4200

Fax

(318) 561-4205

NPI assigned

Aug 31, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Stella Immanuel, M.D.NPI 1902947120

Title

Owner

Phone

(318) 730-9760

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

  • Health Service Clinic/Center
  • Shreveport, LA
  • NPI 1104297720
  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

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Stella Grace Immanuel, MD

  • Family Medicine Physician
  • Katy, TX
  • NPI 1902947120

  Pediatrics

  NPD (past) Authorized official
• Jessica Gardner

  • Pediatric Nurse Practitioner
  • Alexandria, LA
  • NPI 1396162244
  NPD (past)

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

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1446508800000",
    "number": "1487766804",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5910 DUBLIN RD",
            "city": "ALEXANDRIA",
            "state": "LA",
            "postal_code": "713035234",
            "telephone_number": "318-561-4200",
            "fax_number": "318-561-4205"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1416 METRO DR",
            "city": "ALEXANDRIA",
            "state": "LA",
            "postal_code": "713013424",
            "telephone_number": "318-561-4200",
            "fax_number": "318-561-4205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN PEDIATRIC CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-31",
        "last_updated": "2015-11-03",
        "status": "A",
        "authorized_official_last_name": "IMMANUEL",
        "authorized_official_first_name": "STELLA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "318-730-9760",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": "LA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1449237",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Southern Sprouts Pediatrics, LLC
• Jasmine Sparks
• Speak Center of Louisiana
• Kaitlyn Roddy Spears, OTR/L
• Kelly Hudspeth Spears, APRN, FNP-C

• All providers in Alexandria, LA
• Pediatrics Physician 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.