Healthcare Provider Details

I. General information

NPI: 1629675129
Provider Name (Legal Business Name): APOLLO MEDICAL GROUP OF WELLINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 FERGUSON DR STE 190
CINCINNATI OH
45245-5137
US

IV. Provider business mailing address

PO BOX 4186
SPRINGFIELD IL
62708-4186
US

V. Phone/Fax

Practice location:
  • Phone: 360-903-1036
  • Fax:
Mailing address:
  • Phone: 941-360-1566
  • Fax: 941-358-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: AYMAN ELFAR
Title or Position: MEMBER/MANAGER
Credential: MD
Phone: 941-360-1566