Basic Information
| Provider Information | |||||||||
| NPI: | 1346808490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOW BEND EMERGENCY GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 HIGHLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394665574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013589400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2019 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | FALK | ||||||||
| AuthorizedOfficialFirstName: | LISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3376091221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
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 | 02407308 | 05 | MS | MEDICAID |