Basic Information
| Provider Information | |||||||||
| NPI: | 1396703062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTTSBURG EMERGENCY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827429 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 N GARDNER ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471707751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127523456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAUCHERT | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9197684392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 65934358 | 01 | IN | KY MEDICAID | OTHER | 1172648 | 01 | IN | PASSPORT HEALTH PLAN | OTHER | 000000201878 | 01 | IN | BLUE CROSS & BLUE SHIELD | OTHER | DD6466 | 01 | IN | RAIL ROAD MEDICARE | OTHER |