MEDICARE: AEGIS GROUP PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1700396330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEGIS GROUP PRACTICE LLC

Provider Business Mailing Address
First Line	:	1000 FIANNA WAY # MD5740
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72919-9008
Country	:	US
Telephone Number	:	479-201-6089
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 MAR WALT DR APT 112
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6745
Country	:	US
Telephone Number	:	800-444-6845
Fax Number	:	844-640-6066

Authorized Official
Title or Position	:	VP-FINANCE
Name	:	MICHAEL MCOLVIN
Credential	:
Telephone Number	:	479-201-2000

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	10/10/2017

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Directions to “AEGIS GROUP PRACTICE LLC ” Practice Location

Language	Start Address	Practice Location

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