Basic Information
| Provider Information | |||||||||
| NPI: | 1720038391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY SPECIALISTS OF WELLINGTON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24085 | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761241085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10101 W FOREST HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617988535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | SINGLEY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8003460747 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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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 | DE2986 | 01 | MEDICARE RAILROAD | OTHER | 97008 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |