Healthcare Provider Details

I. General information

NPI: 1255018388
Provider Name (Legal Business Name): WK SHREVEPORT INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 E BERT KOUNS INDUSTRIAL LOOP STE 100
SHREVEPORT LA
71105-5680
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-629-0220
  • Fax: 318-629-0230
Mailing address:
  • Phone: 318-716-4939
  • Fax: 318-716-4854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY JANE WARD
Title or Position: SENIOR VP FINANCE
Credential:
Phone: 318-716-4939