Healthcare Provider Details

I. General information

NPI: 1598926263
Provider Name (Legal Business Name): EMORY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 W US HIGHWAY 90
LAKE CITY FL
32055-5126
US

IV. Provider business mailing address

PO BOX 1646
LAKE CITY FL
32056-1646
US

V. Phone/Fax

Practice location:
  • Phone: 386-466-1106
  • Fax: 386-466-1821
Mailing address:
  • Phone: 386-466-1106
  • Fax: 386-466-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101243179
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101243179
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHANDLER MOHAN
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 386-466-1106