Provider Demographics
NPI:1720014145
Name:WILLIS-KNIGHTON MEDICAL CENTER MARK RICHARD MAINOUS
Entity Type:Organization
Organization Name:WILLIS-KNIGHTON MEDICAL CENTER MARK RICHARD MAINOUS
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:318-212-7810
Mailing Address - Street 1:2400 HOSPITAL DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2385
Mailing Address - Country:US
Mailing Address - Phone:318-212-7810
Mailing Address - Fax:318-212-7815
Practice Address - Street 1:2400 HOSPITAL DR
Practice Address - Street 2:SUITE 310
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2385
Practice Address - Country:US
Practice Address - Phone:318-212-7810
Practice Address - Fax:318-212-7815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty