Provider Demographics
NPI:1083948558
Name:ISLAND MEDICAL COOSA VALLEY LLC
Entity Type:Organization
Organization Name:ISLAND MEDICAL COOSA VALLEY LLC
Other - Org Name:PEGASUS EMERGENCY GROUP COOSA VALLEY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCHAMBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-737-2106
Mailing Address - Street 1:PO BOX 92991
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-2991
Mailing Address - Country:US
Mailing Address - Phone:877-716-2447
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:205 MARENGO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-6033
Practice Address - Country:US
Practice Address - Phone:256-768-9191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL115938Medicaid