MEDICARE: SHADOW EMERGENCY PHYSICIANS PLLC

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

General Provider Information

NPI Number	:	1043030919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADOW EMERGENCY PHYSICIANS PLLC

Provider Business Mailing Address
First Line	:	PO BOX 848252
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90084-8252
Country	:	US
Telephone Number	:	954-939-5000
Fax Number	:	877-250-6889

Provider Business Practice Location Address
First Line	:	10290 W FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-2652
Country	:	US
Telephone Number	:	954-939-5000
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	EDWIN HOMANSKY
Credential	:
Telephone Number	:	469-401-2386

Provider Enumeration Date	:	10/15/2024
Last Update Date	:	04/14/2026

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