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General NPI Number Information
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NPI Number | 1720014145
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Entity Type | Organization
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Legal Business Name | WILLIS-KNIGHTON MEDICAL CENTER MARK RICHARD MAINOUS
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Dates
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Enumeration Date | 06/25/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2400 HOSPITAL DR SUITE 310
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City | BOSSIER CITY
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State | LA
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Zip | 71111-2385
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Country | US
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Telephone | 318-212-7810
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Fax | 318-212-7815
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Provider Business Mailing Address
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Address Line | 2400 HOSPITAL DR SUITE 310
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City | BOSSIER CITY
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State | LA
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Zip | 71111-2385
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Country | US
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Telephone | 318-212-7810
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Fax | 318-212-7815
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Authorized Official
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Title or Position | NETWORK ADMINISTRATOR
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Name | GREG J. GAVIN
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Credential |
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Telephone | 318-212-7810
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number |
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License Number State |
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