Basic Information
| Provider Information | |||||||||
| NPI: | 1154367605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE MEAD EMERGENCY PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 861 SW 78TH AVE | ||||||||
| Address2: | SUITE #200B | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546930000 | ||||||||
| FaxNumber: | 9546930005 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 E LAKE MEAD BLVD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | N LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890307120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026497711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCHILLINGER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9546930000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 100502870 | 05 | NV | MEDICAID |