=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649608795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON LAKE EMERGENCY PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2013
-----------------------------------------------------
Last Update Date | 03/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1373 E STATE ROAD 62
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47250-7328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-801-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 37979
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19101-0579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-838-2371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | KAREN VAUGHN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------