Basic Information
| Provider Information | |||||||||
| NPI: | 1528307238 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK TRANSPLANT PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2751 ALBERT L BICKNELL DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124275 | ||||||||
| FaxNumber: | 3182124555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 ALBERT L BICKNELL DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124275 | ||||||||
| FaxNumber: | 3182124555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2013 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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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 | 204F00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery |
No ID Information.