Provider Demographics
NPI:1356309843
Name:SOMERVILLE EMERGENCY SERVICES, LLC
Entity Type:Organization
Organization Name:SOMERVILLE EMERGENCY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUNKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-805-1300
Mailing Address - Street 1:PO BOX 532893
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-2893
Mailing Address - Country:US
Mailing Address - Phone:904-805-1300
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:214 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9737
Practice Address - Country:US
Practice Address - Phone:901-465-3594
Practice Address - Fax:904-805-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3727937Medicaid
TN=========OtherCHAMPUS
TN=========OtherCHAMPUS