Basic Information
| Provider Information | |||||||||
| NPI: | 1568461572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIS KNIGHTON MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32600 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711302600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124877 | ||||||||
| FaxNumber: | 3182124192 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124877 | ||||||||
| FaxNumber: | 3182124192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 3182124877 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 232 | LA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1747572 | 05 | LA | MEDICAID |