Provider Demographics
NPI:1861554297
Name:SHREVEPORT ANESTHESIA SERVICES
Entity type:Organization
Organization Name:SHREVEPORT ANESTHESIA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-635-4269
Mailing Address - Street 1:9441 LBJ FWY STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4500
Mailing Address - Country:US
Mailing Address - Phone:972-664-6963
Mailing Address - Fax:770-237-4731
Practice Address - Street 1:2600 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3908
Practice Address - Country:US
Practice Address - Phone:972-664-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1949124Medicaid
LACE9481OtherRAILROAD MEDICARE
LA5F898Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER