Basic Information
| Provider Information | |||||||||
| NPI: | 1578865325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETTIS EMERGENCY GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373541153 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 E 14TH ST | ||||||||
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| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653015972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608268833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | FALK | ||||||||
| AuthorizedOfficialFirstName: | LISHA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 8008939698 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 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 | 1578865325 | 05 | MO | MEDICAID |