Provider Demographics
NPI:1023074549
Name:WK PEDIATRIC INTENSIVIST
Entity type:Organization
Organization Name:WK PEDIATRIC INTENSIVIST
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:318-212-3868
Mailing Address - Street 1:2510 BERT KOUN LOOP RM 4003
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3119
Mailing Address - Country:US
Mailing Address - Phone:318-212-5665
Mailing Address - Fax:318-212-5698
Practice Address - Street 1:2510 BERT KOUN LOOP RM 4003
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3119
Practice Address - Country:US
Practice Address - Phone:318-212-5665
Practice Address - Fax:318-212-5698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1099091Medicaid