Covered Entity Details

DSH190111AR WILLIS KNIGHTON MEDICAL CENTER, INC. (Terminated) - information as of 4/25/2025 5:47:44 PM

Main Details

Name

WILLIS KNIGHTON MEDICAL CENTER, INC.

Subdivision Name

WILLIS-KNIGHTON SOUTH HOSPITAL - OUTPT SPCH THPY

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH190111AR

Medicare Provider Number

190111

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/5/2017

Participating Start Date

4/1/2017

Participating Approval Date

3/13/2017

Last Recertification Date

8/17/2018

Termination Date
Termination Reason

1/1/2019
Business decision by the Covered Entity

Contacts

Authorizing Official

Willis-Knighton Medical Center
Mary Jane Ward, Senior Vice President - CFO
(318) 212-4384

Primary Contact

Willis-Knighton Medical Center
TESSA ALBRITTON, DIV. DIRECTOR OF PHARMACY
(318) 212-4039

Addresses

Street Address

2530 BERT KOUNS IND LOOP SUITE 148
SHREVEPORT, LA 71118

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
LA	1747572
		1568461572,1124170691

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH190111A	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS KNIGHTON SOUTH HOSPITAL	2510 BERT KOUNS	SHREVEPORT	LA	Terminated
DSH190111AA	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO - CT	7925 YOUREE DR	SHREVEPORT	LA	Active
DSH190111AB	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO - MRI	7925 YOUREE DR	SHREVEPORT	LA	Active
DSH190111AC	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - CANCER TREATMNT	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111AD	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - CHEMO	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111AE	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. CANCER CENTER -CAN CTR OCC THPY	2600 KINGS HWY	SHREVEPORT	LA	Terminated
DSH190111AF	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. CANCER CENTER -PT CANCER - PHY THPY	2600 KINGS HWY	SHREVEPORT	LA	Terminated
DSH190111AG	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - PET SCAN	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111AH	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - MRI	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111AJ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - CT SCAN	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111AK	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - PROTON THERAPY	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111AM	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - ARC THERAPY	2520 BERT KOUNS IND. LOOP #100	SHREVEPORT	LA	Terminated
DSH190111AP	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - AUDIOLOGY	2530 W BERT KOUNS IND. LOOP SUITE 131	SHREVEPORT	LA	Terminated
DSH190111AQ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS KNIGHTON SOUTH - OUTPT OCC THPY	2530 BERT KOUNS IND. LOOP SUITE 148	SHREVEPORT	LA	Terminated
DSH190111AR	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OUTPT SPCH THPY	2530 BERT KOUNS IND LOOP SUITE 148	SHREVEPORT	LA	Terminated
DSH190111AS	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OUTPT PHYS THPY	2530 BERT KOUNS IND. LOOP SUITE 148	SHREVEPORT	LA	Terminated
DSH190111AT	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKS - SOUTH BREAST CENTER	2530 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111AU	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - EMERGENCY ROOM	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111AV	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - PHYSICAL THPY	2510 BERT KOUNS	SHREVEPORT	LA	Terminated
DSH190111AW	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - RESPIRATORY THY	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111AX	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - MRI	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111AY	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - CT SCAN	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111AZ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - NUCLEAR MED	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111B	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER	8001 YOUREE	SHREVEPORT	LA	Terminated
DSH190111BA	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - ULTRASOUND	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BB	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OUTPT IMAGING	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BC	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - X-RAY DIAG	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BD	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - G.I. LAB	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BE	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - ANESTHESIA	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BF	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - LABOR & DELVERY	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BG	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - PACU/DAY SURG	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BH	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OPERATING ROOM	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111BJ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - EMERGENCY ROOM	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BK	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - CHEMO	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BL	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - OUTPT OCC THPY	8001 YOUREE DR	SHREVEPORT	LA	Terminated
DSH190111BM	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - OCCUP THERAPY	8001 YOUREE DR	SHREVEPORT	LA	Terminated
DSH190111BN	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - PHYSICAL THPY	8001 YOUREE DR	SHREVEPORT	LA	Terminated
DSH190111BP	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - RESPIRATORY THY	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BQ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - MRI	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BR	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - CT SCAN	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BS	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - NUCLEAR MED	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BT	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - DIG ANGIOGRAPHY	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BU	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - ULTRASOUND	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BV	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - X-RAY DIAG	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BW	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - BREAST CLINIC	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BX	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - G.I. LAB	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BY	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - ANESTHESIA	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111BZ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - LABOR & DELVERY	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111C	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. CANCER CENTER	2600 KINGS HIGHWAY	SHREVEPORT	LA	Terminated
DSH190111CA	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - PACU/DAY SURG	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111CB	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - OPERATING ROOM	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111CC	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - CARD, NON-INV	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111CD	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. PIERREMONT HEALTH CENTER - CARDIOLOGY, INV	8001 YOUREE DR	SHREVEPORT	LA	Active
DSH190111CE	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WK SPECIALTY PEDIATRICS CENTER	2032 ELIZABETH ST	SHREVEPORT	LA	Active
DSH190111CF	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL- PEDS ENT CTR - WK HEARING CENTER AND PEDIATRIC ENT -WKS	2508 BERT KOUNS SUITE 103	SHREVEPORT	LA	Terminated
DSH190111CG	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	W.K. CANCER CENTER -ENT/CANCER SURG - WK CTR FOR HEAD/NECK CANCER & RECON SX	2600 KINGS HWY SUITE 120	SHREVEPORT	LA	Terminated
DSH190111CH	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	HEART & VASCULAR CLINIC - WK Heart & Vascular Clinic	2727 Hearne Ave	Shreveport	LA	Active
DSH190111CJ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	ORAL/MX ONC SURG - WKN OMF/Head & Neck Onc Reconst Sx (Ghali)	2600 Kings Hwy	Shreveport	LA	Terminated
DSH190111CK	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	HEM/ONC CLINIC - WKN Hematology Oncology	2600 Kings Hwy	Shreveport	LA	Active
DSH190111CL	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Renal Dialysis	8001 Youree Dr	Shreveport	LA	Active
DSH190111CM	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - RENAL DIALYSIS	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111CN	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION 2ND FLOOR ANTEPARTUM	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111CP	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION PICU	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111CQ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 8 Tower	8001 Youree Dr	Shreveport	LA	Active
DSH190111CR	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 6 East Stroke Unit	8001 Youree Dr	Shreveport	LA	Active
DSH190111CS	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation ICU	8001 Youree Dr	Shreveport	LA	Active
DSH190111CT	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 7 East	8001 Youree Dr	Shreveport	LA	Active
DSH190111CU	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION 3 WEST ANTEPARTUM	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111CV	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION 2 EAST	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111CW	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION 3 EAST	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111CX	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 4 East	8001 Youree Dr	Shreveport	LA	Active
DSH190111CY	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 6 West	8001 Youree Dr	Shreveport	LA	Active
DSH190111CZ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION ICU	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111D	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	RENAL/LIVER TX CLINIC	2751 ALBERT BICKNELL DR	SHREVEPORT	LA	Active
DSH190111DA	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 5 West	8001 Youree Dr	Shreveport	LA	Active
DSH190111DB	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 4 West	8001 Youree Dr	Shreveport	LA	Active
DSH190111DC	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION 3 WEST	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111DD	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 5 East	8001 Youree Dr	Shreveport	LA	Active
DSH190111DE	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON PIERREMONT - Observation 6 Tower	8001 Youree Dr	Shreveport	LA	Active
DSH190111DF	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Operating Room - Operating Room	2400 Hospital Dr	Bossier	LA	Active
DSH190111DG	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - CT Scan - CT Scan	2400 Hospital Dr	Bossier	LA	Active
DSH190111DH	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - PACU - PACU	2400 Hospital Dr	Bossier	LA	Active
DSH190111DJ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Cardiology, Non-invasive - Cardiology, Non-invasive	2400 Hospital Dr	Bossier	LA	Active
DSH190111DK	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - X-Ray Diagnostics - X-Ray Diagnostics	2400 Hospital Dr	Bossier	LA	Active
DSH190111DL	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Emergency Department - Emergency Department	2400 Hospital Dr	Bossier	LA	Active
DSH190111DM	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Imaging/Pavilion X-ray - Outpatient Imaging/Pavilion X-ray	2449 Hospital Dr	Bossier	LA	Active
DSH190111DN	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - GI Lab - GI Lab	2400 Hospital Dr	Bossier	LA	Active
DSH190111DP	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Willis-Knighton Bossier Health Center - Nuclear Med - Nuclear Med	2400 Hospital Dr	Bossier	LA	Active
DSH190111DQ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Cardiology, Invasive - Cardiology, Invasive	2400 Hospital Dr	Bossier	LA	Active
DSH190111DR	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Surgery Pavilion - Surgery Pavilion	2449 Hospital Dr	Bossier	LA	Active
DSH190111DS	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Surgery Pavilion Anesthesia - Surgery Pavilion Anesthesia	2449 Hospital Dr	Bossier	LA	Active
DSH190111DT	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Surgery Pavilion MRI - Surgery Pavilion MRI	2449 Hospital Dr	Bossier	LA	Active
DSH190111DU	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Labor and Delivery - Labor and Delivery	2400 Hospital Dr	Bossier	LA	Active
DSH190111DV	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center -MRI - MRI	2400 Hospital Dr	Bossier	LA	Active
DSH190111DW	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Digital Angiography - Digital Angiography	2400 Hospital Dr	Bossier	LA	Active
DSH190111DX	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKB - HYPERBARIC CHAMBER	2300 HOSPITAL DR	BOSSIER CITY	LA	Active
DSH190111DY	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Surgery Pavilion PACU - Surgery Pavilion PACU	2449 Hospital Dr	Bossier	LA	Active
DSH190111DZ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKB - ORAL & MAX SURGERY CLINIC	2400 HOSPITAL DR	BOSSIER CITY	LA	Active
DSH190111E	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKS - UROLOGY CLINIC	2508 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111EA	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - CDU-Clinical Decision Unit - CDU-Clinical Decision Unit	2400 Hospital Dr	Bossier	LA	Active
DSH190111EB	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Anesthesia - Anesthesia	2400 Hospital Dr	Bossier	LA	Active
DSH190111EC	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Observation ASSESSMENT UNIT - Observation ASSESSMENT UNIT	2400 Hospital Dr	Bossier	LA	Active
DSH190111ED	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Respiratory Therapy - Respiratory Therapy	2400 Hospital Dr	Bossier	LA	Active
DSH190111EE	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Observation Inpt Renal Dialysis	2400 Hospital Dr	Bossier	LA	Active
DSH190111EF	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Surgery Pavilion CT - Surgery Pavilion CT	2449 Hospital Dr	Bossier	LA	Active
DSH190111EG	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Observation Beds - 3 NORTH	2400 Hospital Dr	Bossier	LA	Active
DSH190111EH	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Observation Beds - 2ND FLOOR (2W)	2400 Hospital Dr	Bossier	LA	Active
DSH190111EJ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Observation Beds - 3RD - TELEMETRY	2400 Hospital Dr	Bossier	LA	Active
DSH190111EK	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Observation Beds - PEDS/WOMENS (2N)	2400 Hospital Dr	Bossier	LA	Active
DSH190111EL	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON SOUTH HOSPITAL - OBSERVATION 2 EAST PEDIATRIC	2510 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111EM	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Observation Beds - 4TH - Stepdown	2400 Hospital Dr	Bossier	LA	Active
DSH190111EN	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Outpatient Observation Beds - ICU	2400 Hospital Dr.	Bossier	LA	Active
DSH190111EP	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Willis-Knighton Bossier Health Center - Bossier Medical Pavilion Breast Center	2449 Hospital Drive	Bossier City	LA	Active
DSH190111EQ	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKP - WK BREAST HEALTH CENTER	7845 YOUREE DR	SHREVEPORT	LA	Active
DSH190111ER	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WK BOSSIER HEALTH CENTER - ULTRASOUND	2400 HOSPITAL DR	BOSSIER CITY	LA	Active
DSH190111ES	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CARDIOLOGY - Willis-Knighton Cardiology	2727 HEARNE AVE	SHREVEPORT	LA	Active
DSH190111F	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKP - UROLOGY CLINIC	8001 YOUREE DR	SHREVEPORT	LA	Terminated
DSH190111G	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKS - ORAL & MAX SURGERY CLINIC	2508 BERT KOUNS	SHREVEPORT	LA	Terminated
DSH190111H	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	O/PT RENAL DIAL	1111 LINE AVE	SHREVEPORT	LA	Active
DSH190111J	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO AMBUL SURGERY	7925 YOUREE DR	SHREVEPORT	LA	Active
DSH190111K	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO ANESTH	7925 YOUREE DR	SHREVEPORT	LA	Active
DSH190111L	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO RECOVERY	7925 YOUREE DR	SHREVEPORT	LA	Active
DSH190111N	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	EYE SURGERY	2611 GREENWOOD RD (3RD FLOOR)	SHREVEPORT	LA	Active
DSH190111P	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	OUTPT GI	2520 BERT KOUNS	SHEVEPORT	LA	Terminated
DSH190111Q	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WILLIS-KNIGHTON CANCER CENTER - RADIATION THERAPY	2600 KINGS HWY	SHREVEPORT	LA	Active
DSH190111R	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO IMAGING	7925 YOUREE DR	SHREVEPORT	LA	Active
DSH190111S	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKS - HYPERBARIC CHAMBER	2530 BERT KOUNS	SHREVEPORT	LA	Active
DSH190111T	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKS OUTPATIENT PT	2530 BERT KOUNS IND LOOP	SHREVEPORT	LA	Terminated
DSH190111U	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	WKP OUTPATIENT PT	7925 YOUREE DR	SHREVEPORT	LA	Terminated
DSH190111V	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	Refractive Surg	2611 Greenwood Rd.	Shreveport	LA	Active
DSH190111W	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	S-H EYE ANES	2611 GREENWOOD RD (3RD FLOOR)	SHREVEPORT	LA	Active
DSH190111X	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO - OUTPT OCC THPY	7925 YOUREE DR #140	SHREVEPORT	LA	Terminated
DSH190111Y	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO - OUTPT PHYS THPY	7925 YOUREE DR #140	SHREVEPORT	LA	Terminated
DSH190111Z	Child	DSH	WILLIS KNIGHTON MEDICAL CENTER, INC.	PORTICO - SPINE-PHY THPY	7925 YOUREE DR SUITE 140	SHREVEPORT	LA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/31/2018 12:00:00 AM	12/19/2018 12:37 PM
Details	State	Update	Termination Request	Active	To Be Terminated	12/19/2018 12:37 PM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	12/19/2018 12:37 PM
Terminations	Termination Effective Date	Update	Termination Request		12/31/2018 12:00:00 AM	12/19/2018 12:37 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	12/19/2018 12:37 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 3:34:04 PM	8/17/2018 8:53:58 AM	8/17/2018 8:53 AM
Details	Last Recertification Date	Update	Recertification		11/8/2017 3:34:04 PM	11/8/2017 3:34 PM
Contacts	Authorizing Official	Insert	Change Request		Ward, Mary Jane Senior Vice President - CFO Willis-Knighton Medical Center 3182124384	10/19/2017 7:45 PM
Details	Entity Name	Update	Change Request	WILLIS-KNIGHTON HEALTH SYSTEMS	WILLIS KNIGHTON MEDICAL CENTER, INC.	10/19/2017 7:45 PM
Contacts	Primary Contact	Update		ALBRITTON, TESSA DIV. DIRECTOR OF PHARMACY 3182124039	ALBRITTON, TESSA DIV. DIRECTOR OF PHARMACY Willis-Knighton Medical Center 3182124039	9/27/2017 9:27 AM
Contacts	Signed By	Insert			Daigle, Charles D. COO 3182124292	8/8/2017 4:18 PM
Contacts	Primary Contact	Insert			ALBRITTON, TESSA DIV. DIRECTOR OF PHARMACY 3182124039	7/17/2017 3:29 PM
Addresses	Main Address	Insert			2530 BERT KOUNS IND LOOP SUITE 148 SHREVEPORT, LA 71118	7/17/2017 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/17/2017 3:23 PM
Medicaid Billing	Medicaid: Number	Insert			1747572	7/17/2017 3:23 PM
Medicaid Billing	Medicaid: State	Insert			LA	7/17/2017 3:23 PM
Medicaid Billing	NPI: Number	Insert			1568461572	7/17/2017 3:23 PM
Medicaid Billing	NPI: Number	Insert			1124170691	7/17/2017 3:23 PM
Dates	Participating Approval Date	Update			3/13/2017 12:00:00 AM	3/13/2017 4:15 PM
Details	State	Update		Pending	Active	3/13/2017 4:15 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	3/13/2017 4:15 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73904	DSH190111AR	2/9/2017 1:13 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73904	1/5/2017 12:29 PM
Details	Last Recertification Date	Insert				1/5/2017 12:29 PM
Details	Grant Number	Insert				1/5/2017 12:29 PM
Details	340B ID	Insert				1/5/2017 12:29 PM
Details	Is Authorizing Official EHB Data	Insert				1/5/2017 12:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/5/2017 12:29 PM
Details	Medicare Provider Number	Insert			190111	1/5/2017 12:29 PM
Details	Entity Name	Insert			WILLIS-KNIGHTON HEALTH SYSTEMS	1/5/2017 12:29 PM
Details	Program Code	Insert			DSH	1/5/2017 12:29 PM
Details	Entity Subname	Insert			WILLIS-KNIGHTON SOUTH HOSPITAL - OUTPT SPCH THPY	1/5/2017 12:29 PM
Dates	Participating Approval Date	Insert				1/5/2017 12:29 PM
Details	State	Insert			Pending	1/5/2017 12:29 PM
Dates	Registration Date	Insert			1/5/2017 12:00:00 AM	1/5/2017 12:29 PM
Dates	Signed By Date	Insert			1/5/2017 12:00:00 AM	1/5/2017 12:29 PM
Dates	Start Date	Insert				1/5/2017 12:29 PM
Terminations	Termination Comments	Insert				1/5/2017 12:29 PM
Terminations	Termination Date	Insert				1/5/2017 12:29 PM
Terminations	Termination Effective Date	Insert				1/5/2017 12:29 PM
Terminations	Termination Reason	Insert				1/5/2017 12:29 PM