Basic Information
| Provider Information | |||||||||
| NPI: | 1912988395 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORT EMERGENCY MEDICAL SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12420 MILESTONE CENTER DR STE 200 | ||||||||
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| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208767111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 BELLE TERRE RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHARLEY | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP LEGAL | ||||||||
| AuthorizedOfficialTelephone: | 2406862300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ESQ | ||||||||
| NPICertificationDate: | 07/30/2020 | ||||||||
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 | WBW991 | 01 | NY | BCBS GROUP NUMBER | OTHER |