MEDICARE: MILL MOUNTAIN EMERGENCY GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363LA2100X	Acute Care Nurse Practitioner
3	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1750873683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILL MOUNTAIN EMERGENCY GROUP, LLC

Provider Business Mailing Address
First Line	:	200 CORPORATE BLVD
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3870
Country	:	US
Telephone Number	:	800-893-9698
Fax Number	:

Provider Business Practice Location Address
First Line	:	2706 OGDEN RD
Second Line	:
City	:	CAVE SPRING
State	:	VA
Zip	:	24018-0600
Country	:	US
Telephone Number	:	540-970-8000
Fax Number	:

Authorized Official
Title or Position	:	VP OF CONTRACTING
Name	:	LISHA C FALK
Credential	:
Telephone Number	:	800-893-9698

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	06/06/2018

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