Provider Demographics
NPI:1255624169
Name:WK ORTHOPEDIC SPECIALTY CENTER
Entity type:Organization
Organization Name:WK ORTHOPEDIC SPECIALTY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINSTRATOR
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:318-212-4232
Mailing Address - Street 1:2551 GREENWOOD RD STE 130
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3984
Mailing Address - Country:US
Mailing Address - Phone:318-212-8681
Mailing Address - Fax:318-212-8685
Practice Address - Street 1:2551 GREENWOOD RD STE 130
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3984
Practice Address - Country:US
Practice Address - Phone:318-212-8681
Practice Address - Fax:318-212-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2169939Medicaid
LA5DU01Medicare PIN