Basic Information
| Provider Information | |||||||||
| NPI: | 1699733832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JESUP EMERGENCY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 532855 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303532855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 865 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315450210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124276811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUNKER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN/PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9048051300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 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 | 04134 | 01 | GA | BCBS | OTHER |