Healthcare Provider Details

I. General information

NPI: 1912936196
Provider Name (Legal Business Name): KENNETH W. SANDERS, MD AND WILLIS-KNIGHTON MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 EAST BERT KOUNS SUITE 160
SHREVEPORT LA
71105-5505
US

IV. Provider business mailing address

1811 EAST BERT KOUNS SUITE 160
SHREVEPORT LA
71105-5505
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-3223
  • Fax: 318-212-3989
Mailing address:
  • Phone: 318-212-3223
  • Fax: 318-212-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-3223