=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407235666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERGENCY MEDICINE PHYSICIANS OF ESTILL COUNTY,PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2015
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 MERCY CT
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4535 DRESSLER RD NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44718-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
Fax | 330-493-8677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE CHAIRMAN
-----------------------------------------------------
Name | DOMINIC BAGNOLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------