Healthcare Provider Details

I. General information

NPI: 1386116309
Provider Name (Legal Business Name): WALKER LAKE INTENSIVIST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-3000
  • Fax:
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 Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID S SCHILLINGER
Title or Position: PRESIDENT
Credential: MD
Phone: 800-893-9698