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	251G00000X	Community Based Hospice Care Agency	17	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	33720	OTHER	LA	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1487693149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIS KNIGHTON MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	3300 ALBERT L BICKNELL DR
Second Line	:	SUITE 3
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3903
Country	:	US
Telephone Number	:	318-212-4697
Fax Number	:	318-212-8377

Provider Business Practice Location Address
First Line	:	3300 ALBERT L BICKNELL DR
Second Line	:	SUITE 3
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3903
Country	:	US
Telephone Number	:	318-212-4697
Fax Number	:	318-212-8377

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MR. ROBERT D HUIE
Credential	:
Telephone Number	:	318-212-4448

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	07/25/2008

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