Provider Demographics
NPI:1518408244
Name:AEGIS GROUP PRACTICE, LLC
Entity Type:Organization
Organization Name:AEGIS GROUP PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCOLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-201-2000
Mailing Address - Street 1:1000 FIANNA WAY # MD4843
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72919-9008
Mailing Address - Country:US
Mailing Address - Phone:479-201-2000
Mailing Address - Fax:479-201-4801
Practice Address - Street 1:201 EVERGREEN TER
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7375
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:2017-03-14
Last Update Date:2017-03-14
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