Provider Demographics
NPI:1437441698
Name:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:WK REGIONAL ORTHOPEDIC AND SPORTS MEDICINE
Other - Org Type:Doing Business As
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:318-212-8780
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:318-212-5886
Mailing Address - Fax:318-212-5889
Practice Address - Street 1:2520 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3130
Practice Address - Country:US
Practice Address - Phone:318-212-5886
Practice Address - Fax:318-212-5889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-06
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty