Healthcare Provider Details

I. General information

NPI: 1346219789
Provider Name (Legal Business Name): BRAD COLVIN MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS LOOP SUITE 207
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

2508 BERT KOUNS LOOP SUITE 207
SHREVEPORT LA
71118-3133
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5360
  • Fax: 318-212-5360
Mailing address:
  • Phone: 318-212-5360
  • Fax: 318-212-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-5343