MEDICARE: DARDANELLE EMERGENCY MEDICINE 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
1	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1396040861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DARDANELLE EMERGENCY MEDICINE LLC

Provider Business Mailing Address
First Line	:	1530 CORNERSTONE BLVD
Second Line	:	SUITE 200
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-7128
Country	:	US
Telephone Number	:	386-274-7800
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N 3RD ST
Second Line	:
City	:	DARDANELLE
State	:	AR
Zip	:	72834-3802
Country	:	US
Telephone Number	:	479-229-4677
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RUBY F YATES
Credential	:	MD
Telephone Number	:	386-274-7800

Provider Enumeration Date	:	01/14/2011
Last Update Date	:	01/14/2011

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