Provider Demographics
NPI:1700077294
Name:WK MID SOUTH ORTHOPEDICS
Entity Type:Organization
Organization Name:WK MID SOUTH ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4232
Mailing Address - Street 1:7925 YOUREE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5127
Mailing Address - Country:US
Mailing Address - Phone:318-424-3400
Mailing Address - Fax:318-798-9562
Practice Address - Street 1:7925 YOUREE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5127
Practice Address - Country:US
Practice Address - Phone:318-424-3400
Practice Address - Fax:318-798-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
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
LA1015130Medicaid
LA5CY99Medicare PIN