MEDICARE: LAKE MEREDITH EMERGENCY PHYSICIANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0093MA	OTHER	TX	GRP BS - BORGER, TX

General Provider Information

NPI Number	:	1003827023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE MEREDITH EMERGENCY PHYSICIANS

Provider Business Mailing Address
First Line	:	815 S PALAFOX ST
Second Line	:	3RD FLR
City	:	PENSACOLA
State	:	FL
Zip	:	32502-5937
Country	:	US
Telephone Number	:	800-444-7009
Fax Number	:	800-305-3233

Provider Business Practice Location Address
First Line	:	200 S MCGEE ST
Second Line	:
City	:	BORGER
State	:	TX
Zip	:	79007-4022
Country	:	US
Telephone Number	:	806-273-1189
Fax Number	:	806-273-1248

Authorized Official
Title or Position	:	PRES, TEXAS EMERGENCY ROOM SERVICES
Name	:	JOSEPH H GATEWOOD
Credential	:	MD
Telephone Number	:	800-444-7009

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	04/20/2008

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