Basic Information
| Provider Information | |||||||||
| NPI: | 1942263991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CMH ER PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12039 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321202039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4347742400 | ||||||||
| FaxNumber: | 4347742401 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BUENA VISTA CIR | ||||||||
| Address2: | |||||||||
| City: | SOUTH HILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239701431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344473151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | LIBBY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4344473151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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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 | 89013N4 | 05 | NC | MEDICAID | 172719 | 01 | ANTHEM BC/BS OF VA | OTHER | CJ8053 | 01 | RAILROAD MEDICARE | OTHER | 23970 | 01 | CHAMPUS | OTHER |