Organization
WK PEDIATRIC INTENSIVIST
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GREG J. GAVIN (NETWORK ADMINISTRATOR)
(318) 212-3868
Entity
Organization
Contact information
Practice address
2510 BERT KOUN LOOP RM 4003, SHREVEPORT, LA 71118-3119
(318) 212-5665
(318) 212-5698
Mailing address
2510 BERT KOUN LOOP RM 4003, SHREVEPORT, LA 71118-3119
(318) 212-5665
(318) 212-5698
Taxonomy
Speciality
Code
Description
License number
State
2080P0203X
Pediatric Critical Care Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1099091
—
LA
Enumeration date
04/24/2006
Last updated
05/09/2018
Update your record
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