Healthcare Provider Details

I. General information

NPI: 1407235666
Provider Name (Legal Business Name): EMERGENCY MEDICINE PHYSICIANS OF ESTILL COUNTY,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MERCY CT
IRVINE KY
40336
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4443
  • Fax:
Mailing address:
  • Phone: 330-493-4443
  • Fax: 330-493-8677

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: DOMINIC BAGNOLI
Title or Position: EXECUTIVE CHAIRMAN
Credential:
Phone: 330-493-4443