Provider Demographics
NPI:1487693149
Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HUIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4448
Mailing Address - Street 1:3300 ALBERT L BICKNELL DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3903
Mailing Address - Country:US
Mailing Address - Phone:318-212-4697
Mailing Address - Fax:318-212-8377
Practice Address - Street 1:3300 ALBERT L BICKNELL DR
Practice Address - Street 2:SUITE 3
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3903
Practice Address - Country:US
Practice Address - Phone:318-212-4697
Practice Address - Fax:318-212-8377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIS KNIGHTON MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-06
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1580104Medicaid
LA33720OtherBLUE CROSS/BLUE SHIELD
LA1580104Medicaid