Basic Information
| Provider Information | |||||||||
| NPI: | 1679990733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PRACTICE ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78785 | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056823303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2016 S MAIN ST | ||||||||
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| City: | MARYVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644682655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605622600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 04/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | KOCH-HOTH | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8004585003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100264122-00 | 05 | NE | MEDICAID | 1679990733 | 05 | IA | MEDICAID | 1679990733 | 05 | MO | MEDICAID |