Healthcare Provider Details

I. General information

NPI: 1508357930
Provider Name (Legal Business Name): MIDWEST EMERGENCY GRAND ISLAND INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 W FAIDLEY AVE
GRAND ISLAND NE
68803-4205
US

IV. Provider business mailing address

PO BOX 797023
SAINT LOUIS MO
63179-7000
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-4600
  • Fax: 904-265-8181
Mailing address:
  • Phone: 888-577-6337
  • Fax: 904-265-8181

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: CARMON L GLOVER
Title or Position: OWNER
Credential: DO
Phone: 888-577-6337