Healthcare Provider Details

I. General information

NPI: 1023430766
Provider Name (Legal Business Name): PROFESSIONAL EMERGENCY MEDICINE MANAGEMENT -- LAKE CHARLES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 OAK PARK BLVD EMERGENCY DEPT
LAKE CHARLES LA
70601-8911
US

IV. Provider business mailing address

PO BOX 722755
NORMAN OK
73070-9088
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-3036
  • Fax:
Mailing address:
  • Phone: 405-240-9381
  • Fax: 405-844-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: AMY D PROVOST
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 337-534-0952