Healthcare Provider Details

I. General information

NPI: 1013965516
Provider Name (Legal Business Name): WAYNESBORO EMERGENCY SERVICES II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 JV MANGUBAT DR
WAYNESBORO TN
38485-2440
US

IV. Provider business mailing address

PO BOX 534114
ATLANTA GA
30353-4114
US

V. Phone/Fax

Practice location:
  • Phone: 931-722-5411
  • Fax: 904-805-1302
Mailing address:
  • Phone: 904-805-1300
  • Fax: 904-805-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT J BUNKER
Title or Position: CHAIRMAN/PRESIDENT/CEO
Credential:
Phone: 904-805-1300