Provider Demographics
NPI:1316399124
Name:AEGIS GROUP PRACTICE LLC
Entity Type:Organization
Organization Name:AEGIS GROUP PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT/CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-372-6779
Mailing Address - Street 1:2601 NETWORK BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9092
Mailing Address - Country:US
Mailing Address - Phone:972-372-6779
Mailing Address - Fax:479-668-0872
Practice Address - Street 1:5050 KIMBALL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-4511
Practice Address - Country:US
Practice Address - Phone:479-201-2000
Practice Address - Fax:479-201-4801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEGIS THERAPIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-05
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty