Basic Information
| Provider Information | |||||||||
| NPI: | 1295080869 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ISLAND MEDICAL SP LLC | ||||||||
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| OtherOrganizationName: | ISLAND MEDICAL SP, LLC-MONROE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12420 MILESTONE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208767111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068623002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2012 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHARLEY | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF LEGAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2406862300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | ESQ | ||||||||
| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.