Provider Demographics
NPI:1215149331
Name:WK BOSSIER PULMONARY & CRITICAL CARE CLINIC
Entity type:Organization
Organization Name:WK BOSSIER PULMONARY & CRITICAL CARE CLINIC
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:318-212-4232
Mailing Address - Street 1:2400 HOSPITAL DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2385
Mailing Address - Country:US
Mailing Address - Phone:318-747-2277
Mailing Address - Fax:318-747-2217
Practice Address - Street 1:2400 HOSPITAL DR
Practice Address - Street 2:SUITE 340
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2385
Practice Address - Country:US
Practice Address - Phone:318-747-2277
Practice Address - Fax:318-747-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1063487Medicaid
LA1063487Medicaid