Basic Information
| Provider Information | |||||||||
| NPI: | 1609146554 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE RIVER EMERGENCY PHYSICIANS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30759 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370400013 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 2053135245 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W 18TH ST | ||||||||
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| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008875762 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | SOMERBY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6159286268 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALIGNMD | ||||||||
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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 |
No ID Information.