Organization
SOUTH SHREVEPORT INTERNAL MEDICINE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GREG J. GAVIN (NETWORK ADMINISTRATOR)
(318) 212-4232
Entity
Organization
Contact information
Practice address
2508 BERT KOUNS INDUSTRIAL LOOP, SUITE 301, SHREVEPORT, LA 71118-3133
(318) 212-5991
(318) 212-5018
Mailing address
2508 BERT KOUNS INDUSTRIAL LOOP, SUITE 301, SHREVEPORT, LA 71118-3133
(318) 212-5991
(318) 212-5018
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1448885
—
LA
Enumeration date
07/05/2006
Last updated
08/30/2022
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