Provider Demographics
NPI:1588877179
Name:WK OIL CITY MEDICAL CLINIC
Entity type:Organization
Organization Name:WK OIL CITY MEDICAL 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 1:103 SOUTH HWY 1
Mailing Address - Street 2:
Mailing Address - City:OIL CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71061
Mailing Address - Country:US
Mailing Address - Phone:318-995-6504
Mailing Address - Fax:318-995-6535
Practice Address - Street 1:103 SOUTH HWY 1
Practice Address - Street 2:
Practice Address - City:OIL CITY
Practice Address - State:LA
Practice Address - Zip Code:71061
Practice Address - Country:US
Practice Address - Phone:318-995-6504
Practice Address - Fax:318-995-6535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1014991Medicaid
LA1014991Medicaid