Healthcare Provider Details

I. General information

NPI: 1295080869
Provider Name (Legal Business Name): ISLAND MEDICAL SP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
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

VIII. Authorized Official

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