Provider Demographics
NPI:1306388343
Name:ETOWAH EMERGENCY PHYSICIANS, LLC
Entity Type:Organization
Organization Name:ETOWAH EMERGENCY PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:H
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-874-5400
Mailing Address - Street 1:PO BOX 21663
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4113
Mailing Address - Country:US
Mailing Address - Phone:770-874-5400
Mailing Address - Fax:
Practice Address - Street 1:2360 ROCKMART HWY
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-6029
Practice Address - Country:US
Practice Address - Phone:770-748-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty