Healthcare Provider Details

I. General information

NPI: 1215307194
Provider Name (Legal Business Name): ISLAND MEDICAL HOSPITALIST LEA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 N LOVINGTON HWY
HOBBS NM
88240-9100
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 844-474-4019
  • Fax:
Mailing address:
  • Phone: 330-994-4409
  • Fax: 330-492-8489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA REESE
Title or Position: PROVIDER ENROLLMENT OFFICER
Credential:
Phone: 855-687-0618