Provider Demographics
NPI:1205862877
Name:NANCY GERMANY MD AND WILLIS-MEDICAL CENTER
Entity Type:Organization
Organization Name:NANCY GERMANY MD AND WILLIS-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:318-687-5500
Mailing Address - Street 1:6821 PINES RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2547
Mailing Address - Country:US
Mailing Address - Phone:318-687-5500
Mailing Address - Fax:318-687-5503
Practice Address - Street 1:6821 PINES RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2547
Practice Address - Country:US
Practice Address - Phone:318-687-5500
Practice Address - Fax:318-687-5503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CK34Medicare PIN