Provider Demographics
NPI:1538193248
Name:EAGLE EMERGENCY PHYSICIANS LLC
Entity type:Organization
Organization Name:EAGLE EMERGENCY PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-838-2371
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:STE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:214-712-2444
Practice Address - Street 1:1000 E SECOND ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915
Practice Address - Country:US
Practice Address - Phone:469-401-2386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019469700001Medicaid
PA1441172OtherBLUE SHIELD
PA1441172OtherBLUE SHIELD
PA1441172OtherBLUE SHIELD
PA088842Medicare ID - Type Unspecified