Healthcare Provider Details

I. General information

NPI: 1669917472
Provider Name (Legal Business Name): SUWANNEE EMERGENCY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 11TH ST SW
LIVE OAK FL
32064-3608
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 386-362-0800
  • Fax: 386-362-7584
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISHA FALK
Title or Position: VP OF CONTRACTING
Credential:
Phone: 337-354-1221