MEDICARE: WILLIS KNIGHTON MEDICAL CENTER & M R MANCHANDIA

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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1992731301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIS KNIGHTON MEDICAL CENTER & M R MANCHANDIA

Provider Business Mailing Address
First Line	:	2706 SHED RD
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-3348
Country	:	US
Telephone Number	:	318-747-5272
Fax Number	:	318-746-9669

Provider Business Practice Location Address
First Line	:	2706 SHED RD
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-3348
Country	:	US
Telephone Number	:	318-747-5272
Fax Number	:	318-746-9669

Authorized Official
Title or Position	:	NETWORK ADMINISTRATOR
Name	:	GREG J GAVIN
Credential	:
Telephone Number	:	318-747-5272

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	06/12/2012

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