Provider Demographics
NPI:1861372633
Name:WKH PHYSICAL MEDICINE PHYSICIANS
Entity type:Organization
Organization Name:WKH PHYSICAL MEDICINE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PHYSICIAN NETWORK
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-716-4891
Mailing Address - Street 1:1111 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3841
Mailing Address - Country:US
Mailing Address - Phone:318-716-4950
Mailing Address - Fax:
Practice Address - Street 1:1111 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3841
Practice Address - Country:US
Practice Address - Phone:318-716-4950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-03
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty