Provider Demographics
NPI:1003847013
Name:PAUL S WILSON MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity Type:Organization
Organization Name:PAUL S WILSON MD AND WILLIS-KNIGHTON MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-3970
Mailing Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5714
Mailing Address - Country:US
Mailing Address - Phone:318-212-3970
Mailing Address - Fax:318-212-3975
Practice Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 230
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5714
Practice Address - Country:US
Practice Address - Phone:318-212-3970
Practice Address - Fax:318-212-3975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty