Provider Demographics
NPI:1093762353
Name:EMERGENCY PROFESSIONAL SERVICES, INC.
Entity Type:Organization
Organization Name:EMERGENCY PROFESSIONAL SERVICES, INC.
Other - Org Name:EMERGENCY PROFESSIONAL SERVICES OF OHIO, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOLLISON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-842-7990
Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4316
Mailing Address - Fax:
Practice Address - Street 1:230 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SEAMAN
Practice Address - State:OH
Practice Address - Zip Code:45679-8002
Practice Address - Country:US
Practice Address - Phone:937-386-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCA8447OtherMEDICARE TRAVELERS RRGA
OHCA8447OtherMEDICARE TRAVELERS RRGA
OH=========OtherCARESOURCE
OH=========OtherCHAMPUS-TRICARE
OH=========OtherCHAMPUS-TRICARE