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	:	1467232348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADOW EMERGENCY PHYSICIANS PLLC

Provider Business Mailing Address
First Line	:	PO BOX 13917
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19101-3917
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6625 N 5TH ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-1341
Country	:	US
Telephone Number	:	702-388-4000
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	KAREN VAUGHN
Credential	:
Telephone Number	:	404-450-4684

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	10/12/2023

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