Provider Demographics
NPI:1477519858
Name:CHARLES HARGON MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity type:Organization
Organization Name:CHARLES HARGON 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:318-212-8620
Mailing Address - Street 1:2600 KINGS HWY
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3950
Mailing Address - Country:US
Mailing Address - Phone:318-212-8620
Mailing Address - Fax:318-212-8625
Practice Address - Street 1:2600 KINGS HWY
Practice Address - Street 2:SUITE 340
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3950
Practice Address - Country:US
Practice Address - Phone:318-212-8620
Practice Address - Fax:318-212-8625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CQ12Medicare PIN