=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295080869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND MEDICAL SP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2012
-----------------------------------------------------
Last Update Date | 06/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 JACKSON ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-862-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12420 MILESTONE CENTER DR STE 200
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20876-7111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-686-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF LEGAL OFFICER
-----------------------------------------------------
Name | MS. AMY CHARLEY
-----------------------------------------------------
Credential | ESQ
-----------------------------------------------------
Telephone | 240-686-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------