MEDICARE: APOLLO MEDICAL GROUP OF WELLINGTON 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	367500000X	Certified Registered Nurse Anesthetist
2	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1629675129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APOLLO MEDICAL GROUP OF WELLINGTON LLC

Provider Business Mailing Address
First Line	:	PO BOX 4186
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62708-4186
Country	:	US
Telephone Number	:	941-360-1566
Fax Number	:	941-358-9818

Provider Business Practice Location Address
First Line	:	4355 FERGUSON DR STE 190
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-5137
Country	:	US
Telephone Number	:	360-903-1036
Fax Number	:

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	AYMAN ELFAR
Credential	:	MD
Telephone Number	:	941-360-1566

Provider Enumeration Date	:	10/07/2020
Last Update Date	:	10/07/2020

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