Provider Demographics
NPI:1003865809
Name:RAYMOND A. COGHLAN MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity Type:Organization
Organization Name:RAYMOND A. COGHLAN 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:318-212-4571
Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-631-9996
Mailing Address - Fax:318-631-9345
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 150
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-631-9996
Practice Address - Fax:318-631-9345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CX64Medicare PIN