Basic Information
| Provider Information | |||||||||
| NPI: | 1265529648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK NORTH PULMONARY & CRITICAL CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 LOUISIAN AVE. | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128546 | ||||||||
| FaxNumber: | 3182124153 | ||||||||
| Practice Location | |||||||||
| Address1: | 2551 GREENWOOD RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128946 | ||||||||
| FaxNumber: | 3182124153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 06/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3182124232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1099252 | 05 | LA | MEDICAID |