MEDICARE: EMORY MEDICAL CORPORATION

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	207V00000X	Obstetrics & Gynecology Physician	0101243179	VA
2	208D00000X	General Practice Physician	0101243179	VA
3	207V00000X	Obstetrics & Gynecology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598926263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMORY MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 1646
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32056-1646
Country	:	US
Telephone Number	:	386-466-1106
Fax Number	:	386-466-1821

Provider Business Practice Location Address
First Line	:	4812 W US HIGHWAY 90
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-5126
Country	:	US
Telephone Number	:	386-466-1106
Fax Number	:	386-466-1821

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	CHANDLER MOHAN
Credential	:	MD
Telephone Number	:	386-466-1106

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	03/04/2020

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Directions to “EMORY MEDICAL CORPORATION ” Practice Location

Language	Start Address	Practice Location

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