Provider Demographics
NPI:1194281758
Name:AEGIS MEDICAL SOLUTIONS 1 LLC
Entity type:Organization
Organization Name:AEGIS MEDICAL SOLUTIONS 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-443-4242
Mailing Address - Street 1:1012 DRUID RD E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-5606
Mailing Address - Country:US
Mailing Address - Phone:727-443-4242
Mailing Address - Fax:727-441-1158
Practice Address - Street 1:1012 DRUID RD E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5606
Practice Address - Country:US
Practice Address - Phone:727-443-4242
Practice Address - Fax:727-441-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS6109OtherLICENSE NUMBR