Basic Information
Provider Information | |||||||||
NPI: | 1679037154 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MILROY EMERGENCY GROUP A PROFESSIONAL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 CORPORATE BLVD | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705083870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008939698 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 S 9TH AVE | ||||||||
Address2: |   | ||||||||
City: | YAKIMA | ||||||||
State: | WA | ||||||||
PostalCode: | 989023315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095755061 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2019 | ||||||||
LastUpdateDate: | 01/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FALK | ||||||||
AuthorizedOfficialFirstName: | LISHA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF CONTRACTING | ||||||||
AuthorizedOfficialTelephone: | 8008939698 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
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.