Provider Demographics
NPI:1528419801
Name:ISLAND MEDICAL ATHENS LLC
Entity Type:Organization
Organization Name:ISLAND MEDICAL ATHENS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA PRIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-514-7600
Mailing Address - Street 1:PO BOX 74595
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:
Practice Address - Street 1:700 W MARKET ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2457
Practice Address - Country:US
Practice Address - Phone:256-233-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty