Provider Demographics
NPI:1295080869
Name:ISLAND MEDICAL SP LLC
Entity type:Organization
Organization Name:ISLAND MEDICAL SP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:240-686-2300
Mailing Address - Street 1:12420 MILESTONE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-7111
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:
Practice Address - Street 1:309 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7407
Practice Address - Country:US
Practice Address - Phone:406-862-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2304887Medicaid
LADT0920OtherRAILROAD MEDICARE
LADT0920OtherRAILROAD MEDICARE