=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699819912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WK PIERREMONT INTERNAL MEDICINE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2007
-----------------------------------------------------
Last Update Date | 06/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8001 YOUREE DR SUITE 450
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71115-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-3952
-----------------------------------------------------
Fax | 318-212-3955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8001 YOUREE DR SUITE 450
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71115-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-3952
-----------------------------------------------------
Fax | 318-212-3955
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NETWORK ADMINISTRATOR
-----------------------------------------------------
Name | GREG J. GAVIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-212-4232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------