Healthcare Provider Details

I. General information

NPI: 1578034484
Provider Name (Legal Business Name): AEGIS GROUP PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 2ND ST SW
ROCHESTER MN
55902-2442
US

IV. Provider business mailing address

1000 FIANNA WAY
FORT SMITH AR
72919-9008
US

V. Phone/Fax

Practice location:
  • Phone: 800-444-6845
  • Fax: 479-478-2852
Mailing address:
  • Phone: 479-201-6089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MCOLVIN
Title or Position: VP FINANCE
Credential:
Phone: 479-201-2000