Provider Demographics
NPI:1588715791
Name:WK BOSSIER ORTHOPEDIC & SPORTS
Entity type:Organization
Organization Name:WK BOSSIER ORTHOPEDIC & SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4571
Mailing Address - Street 1:2449 HOSPITAL DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2382
Mailing Address - Country:US
Mailing Address - Phone:318-212-7841
Mailing Address - Fax:318-212-7846
Practice Address - Street 1:2449 HOSPITAL DR
Practice Address - Street 2:SUITE 340
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2382
Practice Address - Country:US
Practice Address - Phone:318-212-7841
Practice Address - Fax:318-212-7846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1458651Medicaid
LADF7538Medicare PIN
LA5CX02Medicare PIN