MEDICARE: LEGATUS EMERGENCY SERVICES

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		IL

General Provider Information

NPI Number	:	1235131558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGATUS EMERGENCY SERVICES

Provider Business Mailing Address
First Line	:	17 GINGER CREEK MDWS
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3508
Country	:	US
Telephone Number	:	618-656-9777
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 GINGER CREEK MDWS
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3508
Country	:	US
Telephone Number	:	618-656-9777
Fax Number	:

Authorized Official
Title or Position	:	HEAD OF THIS FACILITY
Name	:	MATTHEW WILKINSON
Credential	:	MD
Telephone Number	:	800-968-6866

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	08/22/2020

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