1043717341 NPI number — AEGIS GROUP PRACTICE LLC

Table of content: (NPI 1043717341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043717341 NPI number — AEGIS GROUP PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AEGIS GROUP PRACTICE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043717341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4933 OLD GREENWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-6906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-201-6147
Provider Business Mailing Address Fax Number:
479-401-2239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 34TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33711-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-444-6845
Provider Business Practice Location Address Fax Number:
479-478-2852
Provider Enumeration Date:
04/12/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JEFFCOAT
Authorized Official First Name:
BRITT
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VP
Authorized Official Telephone Number:
972-372-6799

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)