| NPI | 1861691057 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER PROVASNIK Supervisor Of Provider Enrollment 800-355-0808 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207P00000X Emergency Medicine |
| Enumeration Date | 2007-07-17 |
| Last Update Date | 2007-07-17 |