Provider Demographics
NPI:1912988395
Name:PORT EMERGENCY MEDICAL SERVICES, P.C.
Entity type:Organization
Organization Name:PORT EMERGENCY MEDICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP LEGAL
Authorized Official - Prefix:
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 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1968
Practice Address - Country:US
Practice Address - Phone:844-474-4019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWBW991OtherBCBS GROUP NUMBER
NY02689476Medicaid
NY02689476Medicaid