Provider Demographics
NPI:1780610824
Name:LAURA KIMBALL-RAVARI MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity type:Organization
Organization Name:LAURA KIMBALL-RAVARI 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:318-212-7902
Mailing Address - Street 1:2449 HOSPITAL DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2399
Mailing Address - Country:US
Mailing Address - Phone:318-212-7902
Mailing Address - Fax:318-212-7905
Practice Address - Street 1:2449 HOSPITAL DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2399
Practice Address - Country:US
Practice Address - Phone:318-212-7902
Practice Address - Fax:318-212-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1780610824Medicaid
LA5CR16Medicare PIN