| Organization Name: | LSU HEALTH SCIENCES CENTER SHREVEPORT FACULTY GROUP PRACTICE |
| NPI Number: | 1013374222 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOHN VICTOR MARYMONT (PRESIDENT) |
| Mailing Address: | 1501 Kings Hwy Shreveport |
| State: | LA US |
| Postal Code: | 711034228 |
| Phone Number: | 3186755241 |
| Fax Number: | 3186755244 |
| NPI Enumeration Date: | 01/19/2016 |
| NPI Last Update Date: | 01/19/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 204E00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Oral & Maxillofacial Surgery |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |