NPIMap

Organization Active NPI

Southern Pediatric Clinic

  • Primary Care Clinic/Center
  • Shreveport, LA
National Provider Identifier
1508237256
Registry record updated Oct 7, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
MD12866R Issued in LA
Legal business name
SOUTHERN PEDIATRIC CLINIC
Practice address
4571 N Market St
Shreveport, LA 71107-2917
Phone
(318) 934-0097
NPI assigned
Oct 7, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 7, 2015

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

Authorized official

Name
Stella Grace Immanuel, MD
Title
MD
Phone
(318) 730-9760

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X MD12866R LA Primary

Addresses

Primary practice location

4571 N Market St
Shreveport, LA 71107-2917

Mailing address

4571 N Market St
Shreveport, LA 71107-2917
Phone (318) 934-0097

National Provider Directory

National Provider Directory
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.

NPI Registry JSON

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

{
    "created_epoch": "1444176000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1444176000000",
    "number": "1508237256",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4571 N MARKET ST",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711072917",
            "telephone_number": "318-934-0097"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4571 N MARKET ST",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711072917",
            "telephone_number": "318-934-0097"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN PEDIATRIC CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-07",
        "last_updated": "2015-10-07",
        "status": "A",
        "authorized_official_last_name": "IMMANUEL",
        "authorized_official_first_name": "STELLA",
        "authorized_official_middle_name": "GRACE",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "318-730-9760",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "LA",
            "license": "MD12866R",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Shreveport, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 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.