Provider Demographics
NPI:1992023998
Name:WK RED RIVER INTERNAL MEDICINE
Entity Type:Organization
Organization Name:WK RED RIVER INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4132
Mailing Address - Street 1:2300 HOSPITAL DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2394
Mailing Address - Country:US
Mailing Address - Phone:318-212-7848
Mailing Address - Fax:318-212-7855
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 320
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2394
Practice Address - Country:US
Practice Address - Phone:318-212-7848
Practice Address - Fax:318-212-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-14
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty