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General NPI Number Information
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NPI Number | 1619490778
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Entity Type | Organization
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Legal Business Name | ISLAND MEDICAL HENDERSON LLC
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Dates
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Enumeration Date | 07/20/2017
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Last Update Date | 06/03/2020
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Provider Practice Location Address
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Address Line | 1305 N ELM ST
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City | HENDERSON
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State | KY
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Zip | 42420-2783
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Country | US
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Telephone | 406-862-3002
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Fax |
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Provider Business Mailing Address
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Address Line | 12420 MILESTONE CENTER DR STE 200
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City | GERMANTOWN
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State | MD
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Zip | 20876-7111
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Country | US
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Telephone | 240-686-2300
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Fax |
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Authorized Official
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Title or Position | CHIEF LEGAL OFFICER
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Name | MS. MICHAELAMY CHARLEY
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Credential | ESQ
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Telephone | 240-686-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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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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