Healthcare Provider Details

I. General information

NPI: 1265529648
Provider Name (Legal Business Name): WK NORTH PULMONARY & CRITICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 GREENWOOD RD SUITE 210
SHREVEPORT LA
71103-3981
US

IV. Provider business mailing address

1202 LOUISIAN AVE.
SHREVEPORT LA
71101
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8946
  • Fax: 318-212-4153
Mailing address:
  • Phone: 318-212-8546
  • Fax: 318-212-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-4232