Provider Demographics
NPI:1194255653
Name:AEGIS GROUP PRACTICE LLC
Entity type:Organization
Organization Name:AEGIS GROUP PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCOLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-201-6100
Mailing Address - Street 1:4933 OLD GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72919-6906
Mailing Address - Country:US
Mailing Address - Phone:479-201-6147
Mailing Address - Fax:479-401-2239
Practice Address - Street 1:493 WESLEY MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2885
Practice Address - Country:US
Practice Address - Phone:800-444-6845
Practice Address - Fax:479-478-2852
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEGIS THERAPIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-18
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty