=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891009437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WK NORTHWEST INTERNAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2010
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8001 YOUREE DR STE 550
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71115-2332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-2984
-----------------------------------------------------
Fax | 318-212-3404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8001 YOUREE DR STE 550
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71115-2332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-2984
-----------------------------------------------------
Fax | 318-212-3404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP WK PHYSICIAN NETWORK
-----------------------------------------------------
Name | JARED THOMAS BEVILLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-719-4950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------