Basic Information
| Provider Information | |||||||||
| NPI: | 1003827023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE MEREDITH EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 S PALAFOX ST | ||||||||
| Address2: | 3RD FLR | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325025937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
| FaxNumber: | 8003053233 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S MCGEE ST | ||||||||
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| City: | BORGER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790074022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062731189 | ||||||||
| FaxNumber: | 8062731248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | GATEWOOD | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES, TEXAS EMERGENCY ROOM SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8004447009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0093MA | 01 | TX | GRP BS - BORGER, TX | OTHER |