Basic Information
| Provider Information | |||||||||
| NPI: | 1356309843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOMERVILLE EMERGENCY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 532893 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303532893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 LAKEVIEW RD | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380689737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014653594 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUNKER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN/PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9048051300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3727937 | 05 | TN | MEDICAID |