Provider Demographics
NPI:1679515118
Name:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:NORTH BOSSIER INTERNAL 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 1:2400 HOSPITAL DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2385
Mailing Address - Country:US
Mailing Address - Phone:318-212-7930
Mailing Address - Fax:318-212-7935
Practice Address - Street 1:2400 HOSPITAL DR
Practice Address - Street 2:SUITE 350
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2385
Practice Address - Country:US
Practice Address - Phone:318-212-7930
Practice Address - Fax:318-212-7935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-11
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1452866Medicaid
LA5CS94Medicare PIN