Provider Demographics
NPI:1134295520
Name:D GENE MACK JR MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity Type:Organization
Organization Name:D GENE MACK JR 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:318-212-4232
Mailing Address - Street 1:1799 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5561
Mailing Address - Country:US
Mailing Address - Phone:318-797-9000
Mailing Address - Fax:318-797-9250
Practice Address - Street 1:1799 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5561
Practice Address - Country:US
Practice Address - Phone:318-797-9000
Practice Address - Fax:318-797-9250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty