Healthcare Provider Details

I. General information

NPI: 1194388082
Provider Name (Legal Business Name): GRENADA EMERGENCY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 AVENT DR
GRENADA MS
38901-5230
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-7000
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISHA C FALK
Title or Position: VP OF CONTRACTING
Credential:
Phone: 337-609-1221