Provider Demographics
NPI:1669455226
Name:WK PINNACLE GASTROENTEROLOGY
Entity Type:Organization
Organization Name:WK PINNACLE GASTROENTEROLOGY
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 1:2551 GREENWOOD RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3981
Mailing Address - Country:US
Mailing Address - Phone:318-212-8710
Mailing Address - Fax:318-212-8699
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 350
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-212-8710
Practice Address - Fax:318-212-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448834Medicaid
LA1448834Medicaid