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General NPI Number Information
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NPI Number | 1164711206
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Entity Type | Organization
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Legal Business Name | EMERGENCY PROVIDERS GROUP LLC
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Dates
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Enumeration Date | 03/29/2011
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Last Update Date | 04/29/2011
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Provider Practice Location Address
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Address Line | 1000 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6708
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Country | US
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Telephone | 850-862-1111
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 741630
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City | ATLANTA
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State | GA
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Zip | 30374-1630
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MARK PENKHUS
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Credential |
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Telephone | 615-344-9551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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