Provider Demographics
NPI:1689619769
Name:R SHANE BARTON MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity Type:Organization
Organization Name:R SHANE BARTON 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:318-798-6700
Mailing Address - Street 1:7925 YOUREE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5538
Mailing Address - Country:US
Mailing Address - Phone:318-798-6700
Mailing Address - Fax:318-798-6799
Practice Address - Street 1:7925 YOUREE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5538
Practice Address - Country:US
Practice Address - Phone:318-798-6700
Practice Address - Fax:318-798-6799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CR03Medicare ID - Type Unspecified