Healthcare Provider Details

I. General information

NPI: 1619490778
Provider Name (Legal Business Name): ISLAND MEDICAL HENDERSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 N ELM ST
HENDERSON KY
42420-2783
US

IV. Provider business mailing address

12420 MILESTONE CENTER DR STE 200
GERMANTOWN MD
20876-7111
US

V. Phone/Fax

Practice location:
  • Phone: 406-862-3002
  • Fax:
Mailing address:
  • Phone: 240-686-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. MICHAELAMY CHARLEY
Title or Position: CHIEF LEGAL OFFICER
Credential: ESQ
Phone: 240-686-2300