Organization
PETTIS EMERGENCY GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISHA C FALK (VP OF CONTRACTING)
(800) 893-9698
Entity
Organization
Contact information
Practice address
601 E 14TH ST, SEDALIA, MO 65301-5972
(660) 826-8833
Mailing address
200 CORPORATE BLVD, LAFAYETTE, LA 70508-3870
(337) 354-1153
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1578865325
—
MO
Enumeration date
11/30/2010
Last updated
01/14/2016
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