Healthcare Provider Details

I. General information

NPI: 1851783955
Provider Name (Legal Business Name): WK INTERNAL MEDICINE AND PEDIATRIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 SHED RD STE 120
BOSSIER CITY LA
71111-5662
US

IV. Provider business mailing address

5751 SHED RD STE 120
BOSSIER CITY LA
71111-5662
US

V. Phone/Fax

Practice location:
  • Phone: 318-935-1922
  • Fax: 318-935-1925
Mailing address:
  • Phone: 318-935-1922
  • Fax: 318-935-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JARED BEVILLE
Title or Position: VP PHYSICIAN NETWORK
Credential:
Phone: 318-716-4891