Basic Information
| Provider Information | |||||||||
| NPI: | 1659793511 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST SIDE EMERGENCY PHYSICIANS, LLP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 921 E FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | KENTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433262020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196730761 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2014 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | DERIK | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8669165259 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.