MEDICARE: WILLIS KNIGHTON MEDICAL CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	65	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	33562	OTHER	LA	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1326093782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIS KNIGHTON MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 32600
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71130-2600
Country	:	US
Telephone Number	:	318-212-4544
Fax Number	:	318-212-4192

Provider Business Practice Location Address
First Line	:	3300 ALBERT L BICKNELL DR
Second Line	:	SUITE 4
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3903
Country	:	US
Telephone Number	:	318-212-4180
Fax Number	:	318-212-4382

Authorized Official
Title or Position	:	DIR DECISION SUPPORT
Name	:	MARY JANE WARD
Credential	:
Telephone Number	:	318-212-4384

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	12/05/2014

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