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NPI Code Detail

MEDICARE: OKALOOSA EMERGENCY GROUP LLC

MEDICARE: OKALOOSA EMERGENCY GROUP LLC
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
1363AM0700XMedical Physician Assistant
2363L00000XNurse Practitioner
3207P00000XEmergency Medicine Physician

General Provider Information

NPI Number : 1336126978
Entity Type Code : Organization
Provider Name (Legal Business Name) : OKALOOSA EMERGENCY GROUP LLC
Provider Business Mailing Address
First Line : 200 CORPORATE BLVD
Second Line :
City : LAFAYETTE
State : LA
Zip : 70508-3870
Country : US
Telephone Number : 800-893-9698
Fax Number :
Provider Business Practice Location Address
First Line : 151 E REDSTONE AVE
Second Line :
City : CRESTVIEW
State : FL
Zip : 32539-5352
Country : US
Telephone Number : 800-893-9698
Fax Number :
Authorized Official
Title or Position : VP CONTRACTING
Name : LISHA C FALK
Credential :
Telephone Number : 800-893-9698
Provider Enumeration Date : 12/26/2005
Last Update Date : 02/16/2016

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Directions to “OKALOOSA EMERGENCY GROUP LLC ” Practice Location

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