Provider Demographics
NPI:1538372883
Name:WK DERMATOLOGY CLINIC
Entity type:Organization
Organization Name:WK DERMATOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-8780
Mailing Address - Street 1:WK BOSSIER MEDICAL OFFICE BLDG 2
Mailing Address - Street 2:2300 HOSPITAL DR, SUITE 400
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2394
Mailing Address - Country:US
Mailing Address - Phone:318-212-7800
Mailing Address - Fax:
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2394
Practice Address - Country:US
Practice Address - Phone:318-212-7800
Practice Address - Fax:318-212-7805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CX94Medicare PIN
LA5R033CX94Medicare PIN