Provider Demographics
NPI:1477554129
Name:PROFESSIONAL EMERGENCY PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL EMERGENCY PHYSICIAN SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VIP FINANCE/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:LIPSCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:301-533-4201
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-4597
Mailing Address - Country:US
Mailing Address - Phone:301-533-4201
Mailing Address - Fax:301-533-4208
Practice Address - Street 1:251 N FOURTH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1375
Practice Address - Country:US
Practice Address - Phone:301-533-4201
Practice Address - Fax:301-533-4208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
777AOtherBLUE CROSS CONSOL
777AOtherB/C GENERAL MOTORS
MA6OtherB/C FEDERAL
777AOtherB/C MD
J748OtherBLUE CROSS EMPIRE
MD407145000Medicaid
777AOtherB/C MT STATE
777AOtherCAREFIRST B/C
777AOtherBLUE CROSS
J748OtherBLUE CROSS EMPIRE
777AOtherBLUE CROSS CONSOL
=========OtherALICARE
=========OtherACORDIA
=========OtherALLIANCE
=========OtherBANKER'S FIDELITY
777AOtherBLUE CROSS
777AOtherB/C GENERAL MOTORS
=========OtherAPWU
MA6OtherB/C FEDERAL
=========OtherALICARE