MEDICARE: AEGIS GROUP PRACTICE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1376323378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEGIS GROUP PRACTICE LLC

Provider Business Mailing Address
First Line	:	4933 OLD GREENWOOD RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-6906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 BALL PARK RD
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-1135
Country	:	US
Telephone Number	:	479-201-6091
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	TRACY MCCALL
Credential	:
Telephone Number	:	479-201-6091

Provider Enumeration Date	:	10/05/2023
Last Update Date	:	10/05/2023

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Directions to “AEGIS GROUP PRACTICE LLC ” Practice Location

Language	Start Address	Practice Location

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