Provider Demographics
NPI:1891009437
Name:WK NORTHWEST INTERNAL MEDICINE
Entity type:Organization
Organization Name:WK NORTHWEST INTERNAL MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP WK 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:318-719-4950
Mailing Address - Street 1:8001 YOUREE DR STE 550
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2332
Mailing Address - Country:US
Mailing Address - Phone:318-212-2984
Mailing Address - Fax:318-212-3404
Practice Address - Street 1:8001 YOUREE DR STE 550
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2332
Practice Address - Country:US
Practice Address - Phone:318-212-2984
Practice Address - Fax:318-212-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2120387Medicaid
5DQ36Medicare PIN