Provider Demographics
NPI:1700165891
Name:WILLIS-KNIGHTON MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:WILLIS-KNIGHTON MEDICAL CENTER, INC
Other - Org Name:WK TRISTATE NEUROLOGY CLINIC
Other - Org Type:Doing Business As
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:318-212-4232
Mailing Address - Street 1:2551 GREENWOOD RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3981
Mailing Address - Country:US
Mailing Address - Phone:318-212-8675
Mailing Address - Fax:318-212-8680
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-212-8675
Practice Address - Fax:318-212-8680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIS-KNIGHTON MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-08
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty